Healthcare Provider Details

I. General information

NPI: 1184142879
Provider Name (Legal Business Name): SCOTT COOPER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2017
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

266 ORVIN LANCE DR STE 5
BLUE RIDGE GA
30513-8054
US

IV. Provider business mailing address

266 ORVIN LANCE DR STE 5
BLUE RIDGE GA
30513-8054
US

V. Phone/Fax

Practice location:
  • Phone: 706-450-6602
  • Fax: 706-450-6603
Mailing address:
  • Phone: 706-450-6602
  • Fax: 706-450-6603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number13887
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: