Provider Demographics
NPI:1710935374
Name:COOPER, MINDY (CRNA)
Entity Type:Individual
Prefix:
First Name:MINDY
Middle Name:
Last Name:COOPER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 E MISSOURI AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-1351
Mailing Address - Country:US
Mailing Address - Phone:602-262-8900
Mailing Address - Fax:
Practice Address - Street 1:645 E MISSOURI AVE STE 300
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-1351
Practice Address - Country:US
Practice Address - Phone:602-262-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2018-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO085007367500000X
AZ218585367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO430039496OtherRAILROAD MEDICARE
MO913594438Medicaid