Basic Information
| Provider Information | |||||||||
| NPI: | 1063696425 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOK | ||||||||
| FirstName: | GINA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 617 | ||||||||
| Address2: | |||||||||
| City: | SOMERTON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853500617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283157910 | ||||||||
| FaxNumber: | 2897226113 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 W RIVERSIDE DR STE 4 | ||||||||
| Address2: | |||||||||
| City: | PARKER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853445119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9282564110 | ||||||||
| FaxNumber: | 9287226113 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2007 | ||||||||
| LastUpdateDate: | 04/12/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 04/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R28493 | ND | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 247215 | AZ | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP2300X | R28492 | ND | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | 363LP2300X | 247215 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 247215 | 01 | AZ | CERTIFIED NURSE PRACTITIONER LICENSE | OTHER | 19956 | 05 | ND | MEDICAID |