Provider Demographics
NPI:1750316980
Name:COOPER, MARK EMANUEL (RN)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:EMANUEL
Last Name:COOPER
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:13916 HOWLETT LINE DR
Mailing Address - Street 2:
Mailing Address - City:COLONIAL HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:23834-5865
Mailing Address - Country:US
Mailing Address - Phone:804-530-8335
Mailing Address - Fax:
Practice Address - Street 1:1201 BROAD ROCK BLVD
Practice Address - Street 2:MCGUIRE VA MEDICAL CENTER
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23249-0001
Practice Address - Country:US
Practice Address - Phone:804-675-5000
Practice Address - Fax:804-675-5585
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0001125551163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health