Healthcare Provider Details

I. General information

NPI: 1295397933
Provider Name (Legal Business Name): MICHAEL THOMAS COOK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2019
Last Update Date: 12/14/2023
Certification Date: 12/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4254 JACKSON HWY
CHEHALIS WA
98532-8424
US

IV. Provider business mailing address

2690 NE KRESKY AVE
CHEHALIS WA
98532-2412
US

V. Phone/Fax

Practice location:
  • Phone: 360-996-6603
  • Fax: 360-996-6604
Mailing address:
  • Phone: 360-330-9595
  • Fax: 360-330-9560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD61420065
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: