Provider Demographics
NPI:1144261249
Name:COOPER, DEBRA (DO)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:COOPER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 12TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28601-2798
Mailing Address - Country:US
Mailing Address - Phone:828-328-2941
Mailing Address - Fax:828-328-4049
Practice Address - Street 1:52 12TH AVE NE
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28601-2798
Practice Address - Country:US
Practice Address - Phone:828-328-2941
Practice Address - Fax:828-328-4049
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34006196C207P00000X
CA20A10878207Q00000X
NC2017-00569207Q00000X
AZ4361207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ069131Medicaid
NC1144261249Medicaid
OH0161257Medicaid
OHC00808693Medicare PIN