Provider Demographics
NPI:1548811037
Name:KOPPERUD, TAYLER SUZANNE (RCS, RVS)
Entity type:Individual
Prefix:MRS
First Name:TAYLER
Middle Name:SUZANNE
Last Name:KOPPERUD
Suffix:
Gender:F
Credentials:RCS, RVS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4959 PALO VERDE ST STE 208C-4
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:CA
Mailing Address - Zip Code:91763-2360
Mailing Address - Country:US
Mailing Address - Phone:909-675-7362
Mailing Address - Fax:
Practice Address - Street 1:4959 PALO VERDE ST STE 208C-4
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:CA
Practice Address - Zip Code:91763-2360
Practice Address - Country:US
Practice Address - Phone:909-675-7362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-25
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00868169246XS1301X, 246XC2903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246XS1301XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist CardiovascularSonography
No246XC2903XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist CardiovascularVascular Specialist