Provider Demographics
NPI:1316196959
Name:COOPER, ESTACIA D (CNP)
Entity Type:Individual
Prefix:
First Name:ESTACIA
Middle Name:D
Last Name:COOPER
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:ESTACIA
Other - Middle Name:DIANN
Other - Last Name:THROWER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 268838
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73126-8838
Mailing Address - Country:US
Mailing Address - Phone:918-619-4400
Mailing Address - Fax:918-619-4216
Practice Address - Street 1:4444 E 41ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-2527
Practice Address - Country:US
Practice Address - Phone:918-619-4400
Practice Address - Fax:918-619-4216
Is Sole Proprietor?:No
Enumeration Date:2008-09-18
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK80155363LX0001X, 364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
No364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200245210AMedicaid
OH0083912Medicaid
OH3025372Medicaid
OH9389631Medicare PIN