Provider Demographics
NPI:1760577043
Name:COOK, KELLY R (PA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:R
Last Name:COOK
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:580 S DENTON TAP RD STE 123
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-4099
Mailing Address - Country:US
Mailing Address - Phone:972-462-0762
Mailing Address - Fax:972-393-2133
Practice Address - Street 1:580 S DENTON TAP RD STE 123
Practice Address - Street 2:
Practice Address - City:COPPELL
Practice Address - State:TX
Practice Address - Zip Code:75019-4099
Practice Address - Country:US
Practice Address - Phone:972-462-0762
Practice Address - Fax:972-393-2133
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXPA03756363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXQ07338Medicare UPIN
TX8J2515Medicare PIN
TX8L13509Medicare PIN