Provider Demographics
NPI:1598863532
Name:COOPER, CARTER WELCH (PA-C)
Entity Type:Individual
Prefix:
First Name:CARTER
Middle Name:WELCH
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 1:1150 HAMMOND DR STE 400
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-8617
Mailing Address - Country:US
Mailing Address - Phone:404-256-2633
Mailing Address - Fax:404-255-6532
Practice Address - Street 1:1150 HAMMOND DR STE 400
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-8617
Practice Address - Country:US
Practice Address - Phone:404-256-2633
Practice Address - Fax:404-255-6532
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003082363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA101457295BMedicaid
GA97BBDBHMedicare ID - Type Unspecified