Provider Demographics
NPI:1154325611
Name:COOK, GARY S (PA)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:S
Last Name:COOK
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1207 N VIRGINIA ST
Mailing Address - Street 2:
Mailing Address - City:PORT LAVACA
Mailing Address - State:TX
Mailing Address - Zip Code:77979-2506
Mailing Address - Country:US
Mailing Address - Phone:361-746-1588
Mailing Address - Fax:361-400-1588
Practice Address - Street 1:1207 N VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:PORT LAVACA
Practice Address - State:TX
Practice Address - Zip Code:77979-2506
Practice Address - Country:US
Practice Address - Phone:361-746-1588
Practice Address - Fax:361-400-1588
Is Sole Proprietor?:No
Enumeration Date:2005-06-11
Last Update Date:2014-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA0086363AM0700X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX453897Medicaid
TX107606901Medicare ID - Type UnspecifiedRHC NUMBER
TX453897Medicaid
TXS19460Medicare UPIN