Provider Demographics
NPI:1568630135
Name:COOK, MATTHEW S (PA-C)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:S
Last Name:COOK
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 5579
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97708-5579
Mailing Address - Country:US
Mailing Address - Phone:541-706-5811
Mailing Address - Fax:541-706-5867
Practice Address - Street 1:2042 NE WILLIAMSON CT
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-3760
Practice Address - Country:US
Practice Address - Phone:541-706-6905
Practice Address - Fax:541-706-6906
Is Sole Proprietor?:No
Enumeration Date:2008-02-15
Last Update Date:2020-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002061363AM0700X
ORPA150453363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR00887737OtherMEDICARE RAILROAD
OR500614079Medicaid
OR00887737OtherMEDICARE RAILROAD