Provider Demographics
NPI:1770827628
Name:COOK, STACY
Entity Type:Individual
Prefix:MS
First Name:STACY
Middle Name:
Last Name:COOK
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:STACY
Other - Middle Name:
Other - Last Name:GROSS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 13518
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80902-0518
Mailing Address - Country:US
Mailing Address - Phone:757-879-4352
Mailing Address - Fax:
Practice Address - Street 1:1650 COCHRANE CIR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80913-4613
Practice Address - Country:US
Practice Address - Phone:719-526-2092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant