Provider Demographics
NPI:1831191378
Name:COOK, CAROLINE
Entity type:Individual
Prefix:
First Name:CAROLINE
Middle Name:
Last Name:COOK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:933 BRADBURY DR SE
Mailing Address - Street 2:SUITE 2222
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4374
Mailing Address - Country:US
Mailing Address - Phone:505-272-3120
Mailing Address - Fax:
Practice Address - Street 1:1127 UNIVERSITY BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-1740
Practice Address - Country:US
Practice Address - Phone:505-272-5200
Practice Address - Fax:505-272-5750
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM98-PA18363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM75736Medicaid
NMNM009103OtherBLUE CROSS BLUE SHIELD
NMP02485Medicare UPIN
NM400521096Medicare ID - Type UnspecifiedNM MEDICARE GROUP
NM52922OtherPHP SALUD