Provider Demographics
NPI:1467503284
Name:COOPER, LANCE (PT)
Entity Type:Individual
Prefix:
First Name:LANCE
Middle Name:
Last Name:COOPER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 E HERSEY ST STE 1
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97520-1363
Mailing Address - Country:US
Mailing Address - Phone:541-482-5525
Mailing Address - Fax:541-708-5652
Practice Address - Street 1:997 PATTON LN
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-9135
Practice Address - Country:US
Practice Address - Phone:541-941-5170
Practice Address - Fax:541-878-8111
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5130225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR242029Medicaid
OR242029Medicaid