Provider Demographics
NPI:1942453261
Name:COOPER, CRYSTAL M (PA-C)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:M
Last Name:COOPER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:M
Other - Last Name:WEAVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:497 MALL RD
Mailing Address - Street 2:
Mailing Address - City:OAK HILL
Mailing Address - State:WV
Mailing Address - Zip Code:25901-6216
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:900 INDEPENDENCE RD.
Practice Address - Street 2:
Practice Address - City:COAL CITY
Practice Address - State:WV
Practice Address - Zip Code:25823-1240
Practice Address - Country:US
Practice Address - Phone:304-469-2905
Practice Address - Fax:304-683-6903
Is Sole Proprietor?:No
Enumeration Date:2008-10-30
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV466363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810014077Medicaid
WV2031426Medicare PIN
WV2031425Medicare PIN
WVWV0051BMedicare PIN
WV2031424Medicare PIN