Healthcare Provider Details

I. General information

NPI: 1669291365
Provider Name (Legal Business Name): JONAH COOPER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2024
Last Update Date: 12/30/2024
Certification Date: 12/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2537 W STATE ST STE 200
BOISE ID
83702-2200
US

IV. Provider business mailing address

116 HEBERLING ST
BEAVER FALLS PA
15010-1272
US

V. Phone/Fax

Practice location:
  • Phone: 208-336-0895
  • Fax:
Mailing address:
  • Phone: 724-312-8407
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN750796
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number153135
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: