Provider Demographics
NPI:1669456992
Name:COOKLISH, SCOTT R (PA-C)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:R
Last Name:COOKLISH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:2345 COURT DRIVE
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-2176
Mailing Address - Country:US
Mailing Address - Phone:704-865-0077
Mailing Address - Fax:704-867-6401
Practice Address - Street 1:2345 COURT DRIVE
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2176
Practice Address - Country:US
Practice Address - Phone:704-865-0077
Practice Address - Fax:704-867-6401
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103508363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2756224Medicare PIN
NCP66905Medicare UPIN
NC0397730024Medicare NSC