Healthcare Provider Details

I. General information

NPI: 1881949188
Provider Name (Legal Business Name): DOUGLAS G COOK FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2012
Last Update Date: 07/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2355 N WYATT DR SUITE 101
TUCSON AZ
85712-2120
US

IV. Provider business mailing address

PO BOX 188
MARANA AZ
85653-0188
US

V. Phone/Fax

Practice location:
  • Phone: 520-616-4948
  • Fax: 520-616-4958
Mailing address:
  • Phone: 520-682-4111
  • Fax: 520-818-3630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberTAP4567
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP4567
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: