Provider Demographics
NPI:1144774498
Name:COOPER, BRENT J (NP)
Entity Type:Individual
Prefix:MR
First Name:BRENT
Middle Name:J
Last Name:COOPER
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16703 SE MCGILLIVRAY BLVD
Mailing Address - Street 2:STE 120
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-4300
Mailing Address - Country:US
Mailing Address - Phone:360-566-4840
Mailing Address - Fax:360-566-4841
Practice Address - Street 1:16703 SE MCGILLIVRAY BLVD
Practice Address - Street 2:STE 120
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-4300
Practice Address - Country:US
Practice Address - Phone:360-566-4840
Practice Address - Fax:360-566-4841
Is Sole Proprietor?:No
Enumeration Date:2016-08-04
Last Update Date:2016-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60684465363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily