Provider Demographics
NPI:1659463909
Name:COOKE, RICHARD WILLIAM (CRNA)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:WILLIAM
Last Name:COOKE
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:PO BOX 522
Mailing Address - Street 2:IA
Mailing Address - City:FALLBROOK
Mailing Address - State:CA
Mailing Address - Zip Code:92088
Mailing Address - Country:US
Mailing Address - Phone:760-491-0072
Mailing Address - Fax:760-451-9072
Practice Address - Street 1:624 E ELDER STREET
Practice Address - Street 2:
Practice Address - City:FALLBROOK
Practice Address - State:CA
Practice Address - Zip Code:92028
Practice Address - Country:US
Practice Address - Phone:760-728-1191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY58039367500000X
CA403376367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB232835Medicare PIN