Provider Demographics
NPI:1639721095
Name:COOPER, ANDREW (CRNA)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:COOPER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2019 FOX HILL DR APT 12
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-5206
Mailing Address - Country:US
Mailing Address - Phone:616-617-0672
Mailing Address - Fax:
Practice Address - Street 1:900 PEELER ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008-2300
Practice Address - Country:US
Practice Address - Phone:269-345-8618
Practice Address - Fax:269-345-1508
Is Sole Proprietor?:No
Enumeration Date:2019-07-15
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704308923367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704308923OtherMI LICENSE