Provider Demographics
NPI:1861444168
Name:COOPER, KELLY M (PA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:COOPER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:14100 PARKWAY COMMONS DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-6103
Mailing Address - Country:US
Mailing Address - Phone:405-286-9820
Mailing Address - Fax:405-286-9813
Practice Address - Street 1:14100 PARKWAY COMMONS DR
Practice Address - Street 2:SUITE 100
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73134-6103
Practice Address - Country:US
Practice Address - Phone:405-286-9820
Practice Address - Fax:405-286-9813
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2014-02-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK874363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKP00454308OtherMEDICARE RR
OK446586302003OtherBC/BS OF OK
OK446586302001OtherBC/BS
OK200052210AMedicaid
OKP00083013OtherMEDICARE RR
OK446586302003OtherBC/BS OF OK
OK244419502Medicare PIN