Provider Demographics
NPI: | 1821039447 |
---|---|
Name: | COOPER, HOLLY SUE (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | HOLLY |
Middle Name: | SUE |
Last Name: | COOPER |
Suffix: | |
Gender: | F |
Credentials: | MD |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 505 S 336TH ST |
Mailing Address - Street 2: | SUITE 600 |
Mailing Address - City: | FEDERAL WAY |
Mailing Address - State: | WA |
Mailing Address - Zip Code: | 98003-6328 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 253-838-6180 |
Mailing Address - Fax: | 253-838-6418 |
Practice Address - Street 1: | 888 SWIFT BLVD |
Practice Address - Street 2: | |
Practice Address - City: | RICHLAND |
Practice Address - State: | WA |
Practice Address - Zip Code: | 99352-3514 |
Practice Address - Country: | US |
Practice Address - Phone: | 509-946-4611 |
Practice Address - Fax: | 509-942-2757 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2006-06-08 |
Last Update Date: | 2008-05-23 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
WA | MD00042083 | 207P00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207P00000X | Allopathic & Osteopathic Physicians | Emergency Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
WA | 3075CO | Other | BSWA |
WA | 8352189 | Medicaid | |
WA | 0202682 | Other | LIWA |
WA | P00023255 | Medicare PIN | |
WA | GAB37464 | Medicare PIN | |
WA | G8856296 | Medicare PIN | |
WA | 8352189 | Medicaid | |
WA | 0202682 | Other | LIWA |