Provider Demographics
NPI:1851373526
Name:KOOKER, DERRICK D (PA)
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:D
Last Name:KOOKER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 N NEVADA AVE
Mailing Address - Street 2:SUITE
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-6819
Mailing Address - Country:US
Mailing Address - Phone:719-776-7600
Mailing Address - Fax:
Practice Address - Street 1:2222 N NEVADA AVE
Practice Address - Street 2:SUITE
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-6819
Practice Address - Country:US
Practice Address - Phone:719-776-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA961363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100001170Medicaid
KYP00604454OtherRAILROAD MEDICARE
KY7100001170Medicaid
KYP00604454OtherRAILROAD MEDICARE