Provider Demographics
NPI:1164426128
Name:COOK, CONNIE DALE II (PAC)
Entity Type:Individual
Prefix:MR
First Name:CONNIE
Middle Name:DALE
Last Name:COOK
Suffix:II
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:24874-1650
Mailing Address - Country:US
Mailing Address - Phone:304-732-6735
Mailing Address - Fax:
Practice Address - Street 1:600 E MCDONALD AVE
Practice Address - Street 2:
Practice Address - City:MAN
Practice Address - State:WV
Practice Address - Zip Code:25635-1097
Practice Address - Country:US
Practice Address - Phone:304-583-6541
Practice Address - Fax:304-583-6018
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV626363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810000560Medicaid
WVC02025091Medicare ID - Type Unspecified
WV3810000560Medicaid