MEDICARE: MR. SHANE COOK PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	7407	AZ

General Provider Information

NPI Number	:	1114480159
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SHANE COOK PA

Provider Business Mailing Address
First Line	:	1445 E UTOPIA RD
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85024-3622
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1445 E UTOPIA RD
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85024-3622
Country	:	US
Telephone Number	:	602-312-3505
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/08/2019
Last Update Date	:	04/08/2019

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Directions to “ MR. SHANE COOK PA” Practice Location

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