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:
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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:
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Provider Licenses
StateLicense IDTaxonomies
WAMD00042083207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA3075COOtherBSWA
WA8352189Medicaid
WA0202682OtherLIWA
WAP00023255Medicare PIN
WAGAB37464Medicare PIN
WAG8856296Medicare PIN
WA8352189Medicaid
WA0202682OtherLIWA