Basic Information
| Provider Information | |||||||||
| NPI: | 1780695684 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOLEY | ||||||||
| FirstName: | OLEG | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 126 E CHURCH ST STE 2100 | ||||||||
| Address2: | |||||||||
| City: | SOMERSET | ||||||||
| State: | PA | ||||||||
| PostalCode: | 155012271 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8144431281 | ||||||||
| FaxNumber: | 8144433214 | ||||||||
| Practice Location | |||||||||
| Address1: | 126 E CHURCH ST STE 2100 | ||||||||
| Address2: | |||||||||
| City: | SOMERSET | ||||||||
| State: | PA | ||||||||
| PostalCode: | 155012271 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8144431281 | ||||||||
| FaxNumber: | 8144433214 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2006 | ||||||||
| LastUpdateDate: | 03/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | MA001256L | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 001452375 | 01 | PA | BLUE SHIELD PROVIDER # | OTHER |