Provider Demographics
NPI:1508917808
Name:COOPER, SCOTT J (PA-C)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:J
Last Name:COOPER
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:PO BOX 79035
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21279-0035
Mailing Address - Country:US
Mailing Address - Phone:410-337-1020
Mailing Address - Fax:
Practice Address - Street 1:7601 OSLER DR
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-7700
Practice Address - Country:US
Practice Address - Phone:410-337-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0002271363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP23250Medicare UPIN
MDI165Medicare ID - Type Unspecified