Healthcare Provider Details

I. General information

NPI: 1790326353
Provider Name (Legal Business Name): THEIL L COOKE JR. APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2019
Last Update Date: 02/01/2023
Certification Date: 02/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1070 N HILDALE ST # 750
HILDALE UT
84784-7770
US

IV. Provider business mailing address

340 W HARKER AVE # 750
COLORADO CITY AZ
86021-6198
US

V. Phone/Fax

Practice location:
  • Phone: 352-165-4884
  • Fax: 435-216-5969
Mailing address:
  • Phone: 928-377-0629
  • Fax: 435-216-5969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number233616
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number8273152-8900
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License NumberRN178632
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: