Provider Demographics
NPI:1558993352
Name:COUCH, COOPER
Entity Type:Individual
Prefix:
First Name:COOPER
Middle Name:
Last Name:COUCH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-3329
Mailing Address - Country:US
Mailing Address - Phone:719-275-2301
Mailing Address - Fax:
Practice Address - Street 1:121 N 6TH ST
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-3329
Practice Address - Country:US
Practice Address - Phone:719-275-2301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-10
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant