Provider Demographics
NPI:1013570290
Name:COOK, MCKENNAN A (MD)
Entity Type:Individual
Prefix:
First Name:MCKENNAN
Middle Name:A
Last Name:COOK
Suffix:
Gender:M
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:NMCSD 34800 BOB WILSON DRIVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92134-3300
Mailing Address - Country:US
Mailing Address - Phone:619-881-9169
Mailing Address - Fax:
Practice Address - Street 1:NMCSD 34800 BOB WILSON DRIVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-3300
Practice Address - Country:US
Practice Address - Phone:619-881-9169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-15
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider