1780612291 NPI number — DR. NELSON ROGER COOKE M.D

Table of content: DR. NELSON ROGER COOKE M.D (NPI 1780612291)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780612291 NPI number — DR. NELSON ROGER COOKE M.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COOKE
Provider First Name:
NELSON
Provider Middle Name:
ROGER
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
COOKE
Provider Other First Name:
N.
Provider Other Middle Name:
ROGER
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1780612291
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/15/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 421
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LIBERTY LAKE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99019-0421
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-747-2455
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
212 E CENTRAL
Provider Second Line Business Practice Location Address:
STE 440
Provider Business Practice Location Address City Name:
SPOKANE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99208
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-252-9602
Provider Business Practice Location Address Fax Number:
509-789-9031
Provider Enumeration Date:
06/30/2006

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: 2084N0400X , with the licence number:  MD00014697 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 268 . This is a "GROUP HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 35-9723 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4853935 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003168000 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 907228400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1046101 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: KA634 . This is a "BLUE CROSS OF IDAHO" identifier . This identifiers is of the category "OTHER".
  • Identifier: AB32999 . This is a "MDC GROUP" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 31509 . This is a "LABOR AND INDUSTRIES" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: E01203 . This is a "ASURIS" identifier . This identifiers is of the category "OTHER".




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