Provider Demographics
NPI:1164769139
Name:COOPER, MATTHEW GARRETT (CRNA)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:GARRETT
Last Name:COOPER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 W. LAMPASAS STREET
Mailing Address - Street 2:
Mailing Address - City:ENNIS
Mailing Address - State:TX
Mailing Address - Zip Code:75119
Mailing Address - Country:US
Mailing Address - Phone:972-875-0900
Mailing Address - Fax:469-256-2163
Practice Address - Street 1:2201 W. LAMPASAS STREET
Practice Address - Street 2:
Practice Address - City:ENNIS
Practice Address - State:TX
Practice Address - Zip Code:75119
Practice Address - Country:US
Practice Address - Phone:972-875-0900
Practice Address - Fax:469-256-2163
Is Sole Proprietor?:No
Enumeration Date:2013-01-11
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX733188367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered