=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023343977
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VALERIA JACQUENETTE COOPER PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2009
-----------------------------------------------------
Last Update Date | 12/01/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5850 S MAIN ST
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90003-1215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-846-4266
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5850 S MAIN ST
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90003-1215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-846-4266
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | PA20660
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------