Healthcare Provider Details

I. General information

NPI: 1376511451
Provider Name (Legal Business Name): KEITH O COKER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 08/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 CARLTON ST
WAUCHULA FL
33873-3407
US

IV. Provider business mailing address

515 CARLTON ST
WAUCHULA FL
33873-3407
US

V. Phone/Fax

Practice location:
  • Phone: 863-773-6606
  • Fax: 863-773-9542
Mailing address:
  • Phone: 863-773-6606
  • Fax: 863-773-9542

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2367
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: