Provider Demographics
NPI:1508116765
Name:COOPER, MARY LANE (PA/C)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:LANE
Last Name:COOPER
Suffix:
Gender:F
Credentials:PA/C
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3609 BILL HODGES RD
Mailing Address - Street 2:
Mailing Address - City:CLAXTON
Mailing Address - State:GA
Mailing Address - Zip Code:30417-6235
Mailing Address - Country:US
Mailing Address - Phone:912-739-4807
Mailing Address - Fax:912-739-2939
Practice Address - Street 1:3609 BILL HODGES RD
Practice Address - Street 2:
Practice Address - City:CLAXTON
Practice Address - State:GA
Practice Address - Zip Code:30417-6235
Practice Address - Country:US
Practice Address - Phone:912-739-4807
Practice Address - Fax:912-739-2939
Is Sole Proprietor?:No
Enumeration Date:2012-09-14
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA1586363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical