Provider Demographics
NPI:1861453334
Name:COOPER, MARK ABE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ABE
Last Name:COOPER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1895 KINGSLEY AVE.
Mailing Address - Street 2:SUITE 303
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073
Mailing Address - Country:US
Mailing Address - Phone:904-272-6161
Mailing Address - Fax:904-272-9797
Practice Address - Street 1:1895 KINGSLEY AVE.
Practice Address - Street 2:SUITE 303
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073
Practice Address - Country:US
Practice Address - Phone:904-272-6161
Practice Address - Fax:904-272-9797
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2009-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA1799363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA461070816AMedicaid
FL2907216-00Medicaid
FLS52735Medicare UPIN
FL2907216-00Medicaid
FLE04872Medicare PIN
FLE0487Medicare PIN