Provider Demographics
NPI:1003151945
Name:COOPER, RICHARD TODD (NP)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:TODD
Last Name:COOPER
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2375 GAUSE BLVD E
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70461-4142
Mailing Address - Country:US
Mailing Address - Phone:985-643-2200
Mailing Address - Fax:
Practice Address - Street 1:1001 GAUSE BLVD
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-2939
Practice Address - Country:US
Practice Address - Phone:985-643-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-04
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS854822363LA2100X
LAAP07104363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09305086Medicaid
LA2319345Medicaid
MS09305086Medicaid