Provider Demographics
NPI:1063098069
Name:COOKSEY, JOHN CALVIN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:CALVIN
Last Name:COOKSEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7102 CREEKTON DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-6421
Mailing Address - Country:US
Mailing Address - Phone:502-544-4452
Mailing Address - Fax:
Practice Address - Street 1:7102 CREEKTON DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-6421
Practice Address - Country:US
Practice Address - Phone:502-544-4452
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-20
Last Update Date:2022-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTC2568363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant