Provider Demographics
NPI:1528220563
Name:COOPERRIDER, TRICIA L (DO)
Entity Type:Individual
Prefix:
First Name:TRICIA
Middle Name:L
Last Name:COOPERRIDER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 E HICKMAN RD
Mailing Address - Street 2:
Mailing Address - City:WAUKEE
Mailing Address - State:IA
Mailing Address - Zip Code:50263-5011
Mailing Address - Country:US
Mailing Address - Phone:515-987-6610
Mailing Address - Fax:515-987-6957
Practice Address - Street 1:30 E HIGHWAY 6
Practice Address - Street 2:
Practice Address - City:WAUKEE
Practice Address - State:IA
Practice Address - Zip Code:50263-5011
Practice Address - Country:US
Practice Address - Phone:515-987-6610
Practice Address - Fax:515-987-6957
Is Sole Proprietor?:No
Enumeration Date:2008-07-01
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAR8398208000000X
IA4166208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1528220563Medicaid
IA719260225Medicare PIN