Provider Demographics
NPI:1760625404
Name:COOK, NICOLE R (PA)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:R
Last Name:COOK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MISS
Other - First Name:NICOLE
Other - Middle Name:R
Other - Last Name:BARANOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:860 OMNI BLVD STE 303
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-4477
Mailing Address - Country:US
Mailing Address - Phone:757-232-8769
Mailing Address - Fax:
Practice Address - Street 1:704 THIMBLE SHOALS BLVD
Practice Address - Street 2:SUITE 600A
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-4544
Practice Address - Country:US
Practice Address - Phone:757-595-5001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-10
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110003022363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical