Healthcare Provider Details

I. General information

NPI: 1679146732
Provider Name (Legal Business Name): SAMUEL ANNIBALE COOK PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2021
Last Update Date: 07/19/2021
Certification Date: 07/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4701 MELBOURNE PL
COLLEGE PARK MD
20740-2540
US

IV. Provider business mailing address

6737 OLD WATERLOO RD APT 114
ELKRIDGE MD
21075-7114
US

V. Phone/Fax

Practice location:
  • Phone: 301-345-4400
  • Fax: 301-345-4200
Mailing address:
  • Phone: 503-758-4931
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0008045
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: