Basic Information
| Provider Information | |||||||||
| NPI: | 1770876229 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOPER | ||||||||
| FirstName: | CHAD | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1441 WILKINS CIR | ||||||||
| Address2: | |||||||||
| City: | CASPER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826011337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3072332700 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1441 WILKINS CIR | ||||||||
| Address2: | |||||||||
| City: | CASPER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826011337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3072332700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2011 | ||||||||
| LastUpdateDate: | 09/29/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 48391 | KY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RG0100X | 12103A | WY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 152927700 | 05 | WY | MEDICAID |