Basic Information
| Provider Information | |||||||||
| NPI: | 1366427767 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOPER | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 CHURCH STREET | ||||||||
| Address2: | BOX 40 | ||||||||
| City: | CONRAD | ||||||||
| State: | IA | ||||||||
| PostalCode: | 50621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6413662123 | ||||||||
| FaxNumber: | 6413662143 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 CHURCH | ||||||||
| Address2: | BOX 40 | ||||||||
| City: | CONRAD | ||||||||
| State: | IA | ||||||||
| PostalCode: | 506210040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6413662123 | ||||||||
| FaxNumber: | 6413662143 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2005 | ||||||||
| LastUpdateDate: | 07/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 001336 | IA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.