Provider Demographics
NPI:1912085317
Name:COOPER, ELIZABETH ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
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 1:400 SUTTON AVE
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:PA
Mailing Address - Zip Code:19033-1220
Mailing Address - Country:US
Mailing Address - Phone:610-876-5005
Mailing Address - Fax:
Practice Address - Street 1:5800 RIDGE AVE
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19128-1737
Practice Address - Country:US
Practice Address - Phone:215-483-9900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA050630363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA088710SYBMedicare UPIN