Healthcare Provider Details

I. General information

NPI: 1316954787
Provider Name (Legal Business Name): RONALD COOPER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 E 9TH ST
JULESBURG CO
80737-1100
US

IV. Provider business mailing address

900 CEDAR ST
JULESBURG CO
80737-1121
US

V. Phone/Fax

Practice location:
  • Phone: 970-474-3376
  • Fax: 970-474-2461
Mailing address:
  • Phone: 970-474-3376
  • Fax: 970-474-2461

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number591
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: