Provider Demographics
NPI:1003920596
Name:COOPER, ELLEN MICHELE (MD)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:MICHELE
Last Name:COOPER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10051 LAKE AVE STE 4
Mailing Address - Street 2:
Mailing Address - City:TRUCKEE
Mailing Address - State:CA
Mailing Address - Zip Code:96161-4870
Mailing Address - Country:US
Mailing Address - Phone:530-587-7698
Mailing Address - Fax:
Practice Address - Street 1:10051 LAKE AVE STE 4
Practice Address - Street 2:
Practice Address - City:TRUCKEE
Practice Address - State:CA
Practice Address - Zip Code:96161-4870
Practice Address - Country:US
Practice Address - Phone:530-587-7698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAML20008204208600000X
CAA116674208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery