Healthcare Provider Details

I. General information

NPI: 1841739638
Provider Name (Legal Business Name): MELVIN L COOPER JR. AG-ACNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2017
Last Update Date: 08/18/2023
Certification Date: 08/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1106 COLLEGE ST STE C
BASTROP TX
78602-3948
US

IV. Provider business mailing address

101 W LOUIS HENNA BLVD STE 300
AUSTIN TX
78728-1203
US

V. Phone/Fax

Practice location:
  • Phone: 512-244-2895
  • Fax: 512-244-2895
Mailing address:
  • Phone: 512-492-3743
  • Fax: 512-593-4444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAP133259
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP133259
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: