Provider Demographics
NPI:1245857580
Name:COOPER, TARA LATONYA (OTHER)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:LATONYA
Last Name:COOPER
Suffix:
Gender:F
Credentials:OTHER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1743 TROUP HWY
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-5869
Mailing Address - Country:US
Mailing Address - Phone:682-433-2979
Mailing Address - Fax:
Practice Address - Street 1:1743 TROUP HWY
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-5869
Practice Address - Country:US
Practice Address - Phone:903-363-6208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-02
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
247200000X
TX32066800494332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX32066800494OtherPERSONAL