Provider Demographics
NPI:1053627828
Name:COOKS, JUAN C (PA-C)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:C
Last Name:COOKS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 W BELVEDERE AVE
Mailing Address - Street 2:ORTHOPEDIC SURGERY
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-5216
Mailing Address - Country:US
Mailing Address - Phone:410-601-5645
Mailing Address - Fax:410-601-8501
Practice Address - Street 1:2401 W BELVEDERE AVE
Practice Address - Street 2:ORTHOPEDIC SURGERY
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-5216
Practice Address - Country:US
Practice Address - Phone:410-601-5645
Practice Address - Fax:410-601-8501
Is Sole Proprietor?:No
Enumeration Date:2010-08-31
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0004216363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD956LMedicare PIN