Provider Demographics
NPI:1922279272
Name:COOKSEY, MARCUS WARREN (NPF)
Entity Type:Individual
Prefix:
First Name:MARCUS
Middle Name:WARREN
Last Name:COOKSEY
Suffix:
Gender:M
Credentials:NPF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 SW OAK ST
Mailing Address - Street 2:STE. 210
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97204-1817
Mailing Address - Country:US
Mailing Address - Phone:503-988-7468
Mailing Address - Fax:503-988-3015
Practice Address - Street 1:12710 SE DIVISION ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97236-3134
Practice Address - Country:US
Practice Address - Phone:503-988-3601
Practice Address - Fax:503-988-3015
Is Sole Proprietor?:No
Enumeration Date:2008-03-14
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP17762363L00000X
CANPF17762363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR22959Medicaid
OR096511Medicaid
ORR0000WCJHTMedicare Oscar/Certification