Healthcare Provider Details

I. General information

NPI: 1114969003
Provider Name (Legal Business Name): ELISABETH COOPER PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS ELISABETH VANWYKE

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 09/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1035 PLACER ST
REDDING CA
96001-1125
US

IV. Provider business mailing address

PO BOX 992790
REDDING CA
96099-2790
US

V. Phone/Fax

Practice location:
  • Phone: 530-246-5710
  • Fax: 530-229-1206
Mailing address:
  • Phone: 530-246-5710
  • Fax: 530-229-1206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085-002670
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA22308
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: