Provider Demographics
NPI:1942271192
Name:COOKSLEY, RICHARD EDWARD (PA)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:EDWARD
Last Name:COOKSLEY
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:PO BOX 888
Mailing Address - Street 2:
Mailing Address - City:CANYONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97417-0888
Mailing Address - Country:US
Mailing Address - Phone:541-839-4211
Mailing Address - Fax:541-839-4983
Practice Address - Street 1:115 S PINE ST
Practice Address - Street 2:
Practice Address - City:CANYONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97417-9648
Practice Address - Country:US
Practice Address - Phone:541-839-4211
Practice Address - Fax:541-839-4983
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00272363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR930087876OtherRAILROAD MEDICARE
ORPA00272OtherSTATE LICENSE
OR165878Medicaid
ORR106402Medicare PIN
ORS06723Medicare UPIN
OR930087876OtherRAILROAD MEDICARE