Provider Demographics
NPI:1558381442
Name:COOK, RICHARD MYLES (PA)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:MYLES
Last Name:COOK
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1630 HOSPITAL DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4772
Mailing Address - Country:US
Mailing Address - Phone:505-424-0200
Mailing Address - Fax:505-424-6608
Practice Address - Street 1:1630 HOSPITAL DR
Practice Address - Street 2:SUITE A
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4772
Practice Address - Country:US
Practice Address - Phone:505-424-0200
Practice Address - Fax:505-424-6608
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2013-04-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NM96PA-21363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NML9125Medicaid
NML9125Medicaid