Healthcare Provider Details

I. General information

NPI: 1003370230
Provider Name (Legal Business Name): KIMBERLY M COOK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KIMBERLY M ATWATER PA-C

II. Dates (important events)

Enumeration Date: 01/22/2019
Last Update Date: 09/12/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

1650 COCHRANE CIR UNIT MEDDAC
FORT CARSON CO
80913-4604
US

V. Phone/Fax

Practice location:
  • Phone: 601-815-1312
  • Fax:
Mailing address:
  • Phone: 719-526-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA00757
License Number StateMS
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0006218
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: