MEDICARE: COOPERCARE AZ, PLLC

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	207Q00000X	Family Medicine Physician

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
2	AZ0394570	OTHER	AZ	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1922704808
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COOPERCARE AZ, PLLC

Provider Business Mailing Address
First Line	:	20033 N 19TH AVE STE 111
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85027-4247
Country	:	US
Telephone Number	:	623-582-2355
Fax Number	:

Provider Business Practice Location Address
First Line	:	20033 N 19TH AVE STE 111
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85027-4247
Country	:	US
Telephone Number	:	623-582-2355
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MILISSA ANN COOPER
Credential	:	DO
Telephone Number	:	623-582-2355

Provider Enumeration Date	:	02/02/2023
Last Update Date	:	02/02/2023

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Directions to “COOPERCARE AZ, PLLC ” Practice Location

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