Healthcare Provider Details

I. General information

NPI: 1013141621
Provider Name (Legal Business Name): SHANNON SWIFT COOPER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2009
Last Update Date: 12/27/2022
Certification Date: 12/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1309 W MAIN ST
WALNUT RIDGE AR
72476-1430
US

IV. Provider business mailing address

PO BOX 839
WALNUT RIDGE AR
72476-0839
US

V. Phone/Fax

Practice location:
  • Phone: 870-886-3211
  • Fax: 870-886-3616
Mailing address:
  • Phone: 870-886-3211
  • Fax: 870-886-3616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberE8066
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberE8066
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: