Provider Demographics
NPI:1740610856
Name:COOPER, CRYSTAL WESOCKES (PA-C)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:WESOCKES
Last Name:COOPER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:LYNN
Other - Last Name:WESOCKES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9650 GROSS POINT RD STE 3900
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-5085
Mailing Address - Country:US
Mailing Address - Phone:847-570-1700
Mailing Address - Fax:847-982-1098
Practice Address - Street 1:9650 GROSS POINT RD STE 3900
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076-5085
Practice Address - Country:US
Practice Address - Phone:847-570-1700
Practice Address - Fax:847-982-1098
Is Sole Proprietor?:No
Enumeration Date:2013-11-26
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004955363AS0400X, 363A00000X, 208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1633878OtherBCBS IL