Healthcare Provider Details

I. General information

NPI: 1326778861
Provider Name (Legal Business Name): JERRY COHEE RPA/RA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2022
Last Update Date: 06/16/2022
Certification Date: 06/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL PARK BLVD
BRISTOL TN
37620-7453
US

IV. Provider business mailing address

3053 W STATE ST
BRISTOL TN
37620-1720
US

V. Phone/Fax

Practice location:
  • Phone: 423-844-5700
  • Fax:
Mailing address:
  • Phone: 423-968-1144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code243U00000X
TaxonomyRadiology Practitioner Assistant
License NumberRA0000000009
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: