Healthcare Provider Details

I. General information

NPI: 1780695684
Provider Name (Legal Business Name): OLEG COOLEY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 03/11/2021
Certification Date: 03/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 E CHURCH ST STE 2100
SOMERSET PA
15501-2271
US

IV. Provider business mailing address

126 E CHURCH ST STE 2100
SOMERSET PA
15501-2271
US

V. Phone/Fax

Practice location:
  • Phone: 814-443-1281
  • Fax: 814-443-3214
Mailing address:
  • Phone: 814-443-1281
  • Fax: 814-443-3214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberMA001256L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: