Provider Demographics
NPI:1013141621
Name:COOPER, SHANNON SWIFT (MD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:SWIFT
Last Name:COOPER
Suffix:
Gender:F
Credentials:MD
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 839
Mailing Address - Street 2:
Mailing Address - City:WALNUT RIDGE
Mailing Address - State:AR
Mailing Address - Zip Code:72476-0839
Mailing Address - Country:US
Mailing Address - Phone:870-886-3211
Mailing Address - Fax:870-886-3616
Practice Address - Street 1:1309 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WALNUT RIDGE
Practice Address - State:AR
Practice Address - Zip Code:72476-1430
Practice Address - Country:US
Practice Address - Phone:870-886-3211
Practice Address - Fax:870-886-3616
Is Sole Proprietor?:No
Enumeration Date:2009-05-11
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE8066208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR296613Medicaid