Healthcare Provider Details

I. General information

NPI: 1922278738
Provider Name (Legal Business Name): PAM COOPER FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2008
Last Update Date: 09/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 2ND AVE S SUITE 400
MINNEAPOLIS MN
55402-3318
US

IV. Provider business mailing address

10010 DONALD S. POWERS DRIVE
MUNSTER IN
96321
US

V. Phone/Fax

Practice location:
  • Phone: 612-225-1534
  • Fax:
Mailing address:
  • Phone: 219-934-4200
  • Fax: 219-934-6240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209006976
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: