Basic Information
| Provider Information | |||||||||
| NPI: | 1912085317 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOPER | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 SUTTON AVE | ||||||||
| Address2: | |||||||||
| City: | FOLSOM | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190331220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6108765005 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5800 RIDGE AVE | ||||||||
| Address2: | |||||||||
| City: | PHILA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191281737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154839900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | MA050630 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.