Provider Demographics
NPI:1639659337
Name:COOPER, IDALI BARRAZA (PNP)
Entity Type:Individual
Prefix:MRS
First Name:IDALI
Middle Name:BARRAZA
Last Name:COOPER
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:849 MALLETT ST
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79907-2418
Mailing Address - Country:US
Mailing Address - Phone:915-248-7928
Mailing Address - Fax:
Practice Address - Street 1:11331 JAMES WATT DR STE 600
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-6401
Practice Address - Country:US
Practice Address - Phone:915-838-1400
Practice Address - Fax:915-838-1406
Is Sole Proprietor?:No
Enumeration Date:2018-08-21
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP137529363LP2300X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care