Basic Information
Provider Information
NPI: 1003009911
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: COPPINGER
FirstName: CHARLES
MiddleName: E
NamePrefix:  
NameSuffix:  
Credential: PA
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 99371
Address2:  
City: FORT WORTH
State: TX
PostalCode: 761990371
CountryCode: US
TelephoneNumber: 6828851855
FaxNumber: 6828857347
Practice Location
Address1: 1500 COOPER ST
Address2:  
City: FORT WORTH
State: TX
PostalCode: 761042710
CountryCode: US
TelephoneNumber: 6828854405
FaxNumber: 6828854407
Other Information
ProviderEnumerationDate: 08/23/2007
LastUpdateDate: 02/06/2014
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363A00000XPA04463TXY Physician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant 

ID Information
IDTypeStateIssuerDescription
28260180105TX MEDICAID


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