1851476238 NPI number — LOIS MARLENE DISHMAN-COOPER MPAS, PA-C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851476238 NPI number — LOIS MARLENE DISHMAN-COOPER MPAS, PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DISHMAN-COOPER
Provider First Name:
LOIS
Provider Middle Name:
MARLENE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MPAS, PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GOINES
Provider Other First Name:
LOIS
Provider Other Middle Name:
MARLENE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1851476238
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
929 STACEY BURK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLORA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62839-3241
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-662-2131
Provider Business Mailing Address Fax Number:
618-662-3077

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
929 STACEY BURK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLORA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62839-3241
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-662-2131
Provider Business Practice Location Address Fax Number:
618-662-3077
Provider Enumeration Date:
10/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  085-002930 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00004500 . This is a "PA PRESCRIBER NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: PA9101866 . This is a "PA LICENSE NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 085-002930 . This is a "LICENSE NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 291816100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: MED-PAC-LIC-26883 . This is a "STATE LICENSE" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".




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