Provider Demographics
NPI:1811936321
Name:COOK, EDWARD R (CRNA)
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:R
Last Name:COOK
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 1:5319 SW WESTGATE DR
Mailing Address - Street 2:#241
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97221-2432
Mailing Address - Country:US
Mailing Address - Phone:503-297-7223
Mailing Address - Fax:503-297-7603
Practice Address - Street 1:1601 NW HAWTHORNE AVE
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-1041
Practice Address - Country:US
Practice Address - Phone:541-472-4884
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR125794Medicaid
OR125794Medicaid
S01985Medicare UPIN