Provider Demographics
NPI:1326533480
Name:COOK, KRISTA NICOLE (PA)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:NICOLE
Last Name:COOK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1552 W DUPONT AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84116-3651
Mailing Address - Country:US
Mailing Address - Phone:801-726-9043
Mailing Address - Fax:
Practice Address - Street 1:1552 W DUPONT AVE
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84116-3651
Practice Address - Country:US
Practice Address - Phone:801-726-9043
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-29
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X, 390200000X
UT5830482-1206363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No172V00000XOther Service ProvidersCommunity Health Worker
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program