Provider Demographics
NPI:1255333738
Name:COOPER, VIRGINIA CAROL (PA-C)
Entity Type:Individual
Prefix:MS
First Name:VIRGINIA
Middle Name:CAROL
Last Name:COOPER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:950 E BOGARD RD STE 103
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7184
Mailing Address - Country:US
Mailing Address - Phone:907-352-2820
Mailing Address - Fax:907-352-2885
Practice Address - Street 1:950 E BOGARD RD STE 103
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7184
Practice Address - Country:US
Practice Address - Phone:907-352-2820
Practice Address - Fax:907-352-2885
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003339363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA561080766AMedicaid
S93142Medicare UPIN