Provider Demographics
NPI:1598889735
Name:COOPER, GARY SCOTT (PA)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:SCOTT
Last Name:COOPER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:283 MADONNA RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405-5432
Mailing Address - Country:US
Mailing Address - Phone:805-549-8880
Mailing Address - Fax:805-549-8743
Practice Address - Street 1:283 MADONNA RD
Practice Address - Street 2:SUITE B
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-5432
Practice Address - Country:US
Practice Address - Phone:805-549-8880
Practice Address - Fax:805-549-8743
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15219363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA15219OtherPA LICENSE