Provider Demographics
NPI:1326160607
Name:COOPER, TERRELL (CRNA)
Entity Type:Individual
Prefix:MR
First Name:TERRELL
Middle Name:
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 1:1870D INDEPENDENCE SQ STE D
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30338-5150
Mailing Address - Country:US
Mailing Address - Phone:770-396-6190
Mailing Address - Fax:770-396-5541
Practice Address - Street 1:3200 DOWNWOOD CIR NW STE 400
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30327-1624
Practice Address - Country:US
Practice Address - Phone:404-352-2005
Practice Address - Fax:404-352-2008
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAR088127174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA43ZCCBX03Medicare ID - Type Unspecified