Provider Demographics
NPI:1104800770
Name:COOPER, LISETTE TRIANA (MD)
Entity type:Individual
Prefix:DR
First Name:LISETTE
Middle Name:TRIANA
Last Name:COOPER
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:194 WEST SPROUL ROAD, SUITE 105
Mailing Address - Street 2:COATESVILLE VAMC: SPRINGFIELD CBOC
Mailing Address - City:SPRINGFILED
Mailing Address - State:PA
Mailing Address - Zip Code:19064
Mailing Address - Country:US
Mailing Address - Phone:610-383-0289
Mailing Address - Fax:610-543-1738
Practice Address - Street 1:1400 BLACK HORSE HILL ROAD
Practice Address - Street 2:VA MEDICAL CENTER BUILDING 2
Practice Address - City:COATESVILLE
Practice Address - State:PA
Practice Address - Zip Code:19320-2096
Practice Address - Country:US
Practice Address - Phone:610-383-0289
Practice Address - Fax:610-543-1738
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2017-03-30
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
PAMD039876E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011842990008Medicaid
PA0011842990008Medicaid
F15128Medicare UPIN