Provider Demographics
NPI:1366039125
Name:UNDERWOOD, KOOPER HARRISON
Entity Type:Individual
Prefix:
First Name:KOOPER
Middle Name:HARRISON
Last Name:UNDERWOOD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9250 N 3RD ST STE 1003
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-2402
Mailing Address - Country:US
Mailing Address - Phone:214-551-3684
Mailing Address - Fax:
Practice Address - Street 1:9250 N 3RD ST STE 1003
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-2402
Practice Address - Country:US
Practice Address - Phone:214-551-3684
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-28
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant