Provider Demographics
NPI:1831627710
Name:COOPER, MAC (PTA)
Entity type:Individual
Prefix:
First Name:MAC
Middle Name:
Last Name:COOPER
Suffix:
Gender:M
Credentials:PTA
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 1107
Mailing Address - Street 2:
Mailing Address - City:SALMON
Mailing Address - State:ID
Mailing Address - Zip Code:83467-1107
Mailing Address - Country:US
Mailing Address - Phone:208-756-2005
Mailing Address - Fax:
Practice Address - Street 1:802 SHOUP ST
Practice Address - Street 2:
Practice Address - City:SALMON
Practice Address - State:ID
Practice Address - Zip Code:83467-4305
Practice Address - Country:US
Practice Address - Phone:208-756-2005
Practice Address - Fax:208-756-4020
Is Sole Proprietor?:No
Enumeration Date:2017-05-23
Last Update Date:2017-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPTA5126208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation