Provider Demographics
NPI:1477555746
Name:COOPER, CLIFFORD (PA)
Entity Type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:
Last Name:COOPER
Suffix:
Gender:M
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:PO BOX 30731
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33630-3731
Mailing Address - Country:US
Mailing Address - Phone:800-476-8646
Mailing Address - Fax:919-382-3210
Practice Address - Street 1:110 LONGWOOD AVENUE
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-2828
Practice Address - Country:US
Practice Address - Phone:800-476-8646
Practice Address - Fax:919-382-3210
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101412363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291562600Medicaid
FL291562600Medicaid
FLU3412YMedicare ID - Type UnspecifiedGROUP # 34457
FLP00309652Medicare PIN
FLQ24376Medicare UPIN