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General NPI Number Information
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NPI Number | 1477178432
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Entity Type | Individual
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Provider Name | THOMAS RAY COOK
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Gender | Male
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Dates
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Enumeration Date | 06/15/2020
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Last Update Date | 05/18/2022
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Provider Practice Location Address
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Address Line | 1444 PARKWAY DRIVE
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City | BLACKFOOT
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State | ID
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Zip | 83221
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Country | US
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Telephone | 208-785-2600
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Fax |
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Provider Business Mailing Address
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Address Line | 669 S 700 E APT 18
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City | ST GEORGE
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State | UT
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Zip | 84770-2407
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Country | US
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Telephone | 801-657-2232
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA-2180
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License Number State | ID
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