Basic Information
| Provider Information | |||||||||
| NPI: | 1033307939 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOK | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2410 SUSANNAH ST | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376011748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232829011 | ||||||||
| FaxNumber: | 4232820035 | ||||||||
| Practice Location | |||||||||
| Address1: | 2410 SUSANNAH STREET | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376011748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232829011 | ||||||||
| FaxNumber: | 4232820035 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2007 | ||||||||
| LastUpdateDate: | 12/16/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/16/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 305 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1507032 | 05 | TN | MEDICAID |