Provider Demographics
NPI:1417927013
Name:COOK, TIMOTHY P (PA-C)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:P
Last Name:COOK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 PROFESSIONAL PARK DR
Mailing Address - Street 2:SUITE 21
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-6529
Mailing Address - Country:US
Mailing Address - Phone:423-434-6300
Mailing Address - Fax:423-434-6312
Practice Address - Street 1:3 PROFESSIONAL PARK DR
Practice Address - Street 2:SUITE 21
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6529
Practice Address - Country:US
Practice Address - Phone:423-434-6300
Practice Address - Fax:423-434-6312
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1149363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3662661Medicaid
TN3662661Medicare PIN
TNQ24135Medicare UPIN
TN3662661Medicaid