Healthcare Provider Details

I. General information

NPI: 1114082450
Provider Name (Legal Business Name): DARREL L. COOPER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 7TH ST SE
DECATUR AL
35601-3337
US

IV. Provider business mailing address

2875 COUNTY ROAD 170
MOULTON AL
35650-7473
US

V. Phone/Fax

Practice location:
  • Phone: 256-355-2281
  • Fax:
Mailing address:
  • Phone: 205-974-6307
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number44824
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: