Provider Demographics
NPI:1245577659
Name:COOKERLY, SETH ALDEN (PA-C)
Entity Type:Individual
Prefix:
First Name:SETH
Middle Name:ALDEN
Last Name:COOKERLY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603A METHODIST AVE
Mailing Address - Street 2:
Mailing Address - City:PERKINS
Mailing Address - State:OK
Mailing Address - Zip Code:74059-9111
Mailing Address - Country:US
Mailing Address - Phone:405-762-9038
Mailing Address - Fax:918-642-3694
Practice Address - Street 1:40 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:OK
Practice Address - Zip Code:74637-5084
Practice Address - Country:US
Practice Address - Phone:918-642-3291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-07
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2209363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical