Provider Demographics
NPI:1750614483
Name:COOPER, SANDRA M (CRNP)
Entity type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:M
Last Name:COOPER
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2442 BRODHEAD RD
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18020-8910
Mailing Address - Country:US
Mailing Address - Phone:610-758-8011
Mailing Address - Fax:610-758-8013
Practice Address - Street 1:5479 POTTSVILLE PIKE
Practice Address - Street 2:
Practice Address - City:LEESPORT
Practice Address - State:PA
Practice Address - Zip Code:19533-8633
Practice Address - Country:US
Practice Address - Phone:610-916-1050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-14
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP010119363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102509963Medicaid
PA102509963Medicaid