Provider Demographics
NPI:1861654170
Name:COOPER, DONNA M (PA-C)
Entity Type:Individual
Prefix:MS
First Name:DONNA
Middle Name:M
Last Name:COOPER
Suffix:
Gender:F
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 1:545 OLD NORCROSS RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-3389
Mailing Address - Country:US
Mailing Address - Phone:770-963-6300
Mailing Address - Fax:678-287-1664
Practice Address - Street 1:545 OLD NORCROSS RD
Practice Address - Street 2:SUITE 300
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-3389
Practice Address - Country:US
Practice Address - Phone:770-963-6300
Practice Address - Fax:678-287-1664
Is Sole Proprietor?:No
Enumeration Date:2008-06-27
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-01398363A00000X
GA002278363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA843768621AMedicaid
GA511I970663Medicare PIN
NC2759174Medicare PIN