Basic Information
| Provider Information | |||||||||
| NPI: | 1992074116 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOK | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | BRADLEY | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 BLYTHE BLVD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282035812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043552000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 BLYTHE BLVD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282035812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043552000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2011 | ||||||||
| LastUpdateDate: | 11/08/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 216843 | NC | N | Nursing Service Providers | Registered Nurse | 367500000X | 88188 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 8054245 | 05 | NC | MEDICAID | NAN105 | 05 | SC | MEDICAID |