Healthcare Provider Details

I. General information

NPI: 1598889735
Provider Name (Legal Business Name): GARY SCOTT COOPER P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 07/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

283 MADONNA RD SUITE B
SAN LUIS OBISPO CA
93405-5432
US

IV. Provider business mailing address

283 MADONNA RD SUITE B
SAN LUIS OBISPO CA
93405-5432
US

V. Phone/Fax

Practice location:
  • Phone: 805-549-8880
  • Fax: 805-549-8743
Mailing address:
  • Phone: 805-549-8880
  • Fax: 805-549-8743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA15219
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: