Healthcare Provider Details

I. General information

NPI: 1982986238
Provider Name (Legal Business Name): COLLIN DALLAS COOPER P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2011
Last Update Date: 09/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

919 CONESTOGA RD BLUILDING #1 SUITE# 300
BRYN MAWR PA
19010-1352
US

IV. Provider business mailing address

919 CONESTOGA RD BLUILDING #1 SUITE# 300
BRYN MAWR PA
19010-1352
US

V. Phone/Fax

Practice location:
  • Phone: 610-525-6580
  • Fax: 610-525-3664
Mailing address:
  • Phone: 610-525-6580
  • Fax: 610-525-3664

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA054907
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: