MEDICARE: MR. GARY S COOK P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PA0086	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1154325611
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GARY S COOK P.A.

Provider Business Mailing Address
First Line	:	1207 N VIRGINIA ST
Second Line	:
City	:	PORT LAVACA
State	:	TX
Zip	:	77979-2506
Country	:	US
Telephone Number	:	361-746-1588
Fax Number	:	361-400-1588

Provider Business Practice Location Address
First Line	:	1207 N VIRGINIA ST
Second Line	:
City	:	PORT LAVACA
State	:	TX
Zip	:	77979-2506
Country	:	US
Telephone Number	:	361-746-1588
Fax Number	:	361-400-1588

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/11/2005
Last Update Date	:	05/01/2014

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