Healthcare Provider Details

I. General information

NPI: 1568630135
Provider Name (Legal Business Name): MATTHEW S COOK PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2008
Last Update Date: 05/29/2020
Certification Date: 05/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2042 NE WILLIAMSON CT
BEND OR
97701-3760
US

IV. Provider business mailing address

PO BOX 5579
BEND OR
97708-5579
US

V. Phone/Fax

Practice location:
  • Phone: 541-706-6905
  • Fax: 541-706-6906
Mailing address:
  • Phone: 541-706-5811
  • Fax: 541-706-5867

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number002061
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA150453
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: