Healthcare Provider Details

I. General information

NPI: 1518453976
Provider Name (Legal Business Name): CAMERON COOPER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2018
Last Update Date: 01/09/2023
Certification Date: 01/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

576 E HIGHWAY 138 STE 310
STANSBURY PARK UT
84074-4028
US

IV. Provider business mailing address

2321 N 400 E STE 300
TOOELE UT
84074-3440
US

V. Phone/Fax

Practice location:
  • Phone: 801-827-0662
  • Fax:
Mailing address:
  • Phone: 435-833-9180
  • Fax: 435-833-9177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number10961171-1206
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: