Provider Demographics
NPI:1942383393
Name:COOPER, WANTZY (DO)
Entity Type:Individual
Prefix:DR
First Name:WANTZY
Middle Name:
Last Name:COOPER
Suffix:
Gender:F
Credentials:DO
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 9893
Mailing Address - Street 2:
Mailing Address - City:FORT MOHAVE
Mailing Address - State:AZ
Mailing Address - Zip Code:86427-9893
Mailing Address - Country:US
Mailing Address - Phone:760-590-0155
Mailing Address - Fax:760-323-7134
Practice Address - Street 1:1401 BAILEY AVE
Practice Address - Street 2:BLDG 1
Practice Address - City:NEEDLES
Practice Address - State:CA
Practice Address - Zip Code:92363-3103
Practice Address - Country:US
Practice Address - Phone:760-590-0155
Practice Address - Fax:760-323-7134
Is Sole Proprietor?:No
Enumeration Date:2006-10-21
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14611207P00000X, 2086S0129X, 208D00000X
NJMB74255208600000X
AZ005530208D00000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ585877Medicaid
AZZ167087Medicare PIN