Provider Demographics
NPI:1629479621
Name:COOK, NATHAN (PAC)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:COOK
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:890 W ELLIOT RD
Mailing Address - Street 2:STE 102
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85233-5102
Mailing Address - Country:US
Mailing Address - Phone:480-654-5661
Mailing Address - Fax:480-654-5663
Practice Address - Street 1:890 W ELLIOT RD
Practice Address - Street 2:STE 102
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85233-5102
Practice Address - Country:US
Practice Address - Phone:480-654-5661
Practice Address - Fax:480-654-5663
Is Sole Proprietor?:No
Enumeration Date:2014-09-09
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5789363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant