Provider Demographics
NPI:1669413134
Name:COOPER, JANINE LYNN (PA C)
Entity type:Individual
Prefix:
First Name:JANINE
Middle Name:LYNN
Last Name:COOPER
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P. O. BOX 4346 DEPT 205
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77210-4346
Mailing Address - Country:US
Mailing Address - Phone:713-790-5227
Mailing Address - Fax:713-790-5505
Practice Address - Street 1:6560 FANNIN STREET
Practice Address - Street 2:SUITE 1842
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2761
Practice Address - Country:US
Practice Address - Phone:713-790-2089
Practice Address - Fax:713-794-0576
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04724363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8N9697OtherBCBS
TX8G2757Medicare PIN
Q31674Medicare UPIN