Provider Demographics
NPI:1235181280
Name:COOK, ALEXANDER W (PAC)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:W
Last Name:COOK
Suffix:
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 1:332 CONGRESS PARK DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45459-4133
Mailing Address - Country:US
Mailing Address - Phone:800-875-0136
Mailing Address - Fax:937-619-4231
Practice Address - Street 1:3000 MACK RD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-5335
Practice Address - Country:US
Practice Address - Phone:513-870-7001
Practice Address - Fax:513-603-8174
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50001442363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00359448OtherMEDICARE RR/MIDDLETOWN
OHP00105188OtherMEDICARE RR
COPA18092Medicare ID - Type Unspecified
OHP00105188OtherMEDICARE RR
OHP00359448OtherMEDICARE RR/MIDDLETOWN