Provider Demographics
NPI:1407494800
Name:COOPER, LISA P
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:P
Last Name:COOPER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6623 SAN MIGUEL WAY
Mailing Address - Street 2:
Mailing Address - City:CONVERSE
Mailing Address - State:TX
Mailing Address - Zip Code:78109-3773
Mailing Address - Country:US
Mailing Address - Phone:210-749-4458
Mailing Address - Fax:
Practice Address - Street 1:2040 BABCOCK RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4425
Practice Address - Country:US
Practice Address - Phone:210-731-9570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-16
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX967488163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse