Provider Demographics
NPI:1053509042
Name:COOK, PATRICIA ANN (PAC)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:ANN
Last Name:COOK
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 17016
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:VA
Mailing Address - Zip Code:24209-7016
Mailing Address - Country:US
Mailing Address - Phone:423-844-6407
Mailing Address - Fax:866-288-1451
Practice Address - Street 1:1 MEDICAL PARK BLVD
Practice Address - Street 2:STE 250 WEST
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-7430
Practice Address - Country:US
Practice Address - Phone:423-844-6407
Practice Address - Fax:866-288-1451
Is Sole Proprietor?:No
Enumeration Date:2007-10-04
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1043887363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4073911OtherBLUECROSS
TN4073911OtherBLUECROSS