Provider Demographics
NPI:1104939685
Name:COOPER, MARY ALICE (PA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ALICE
Last Name:COOPER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:379 MILLEDGE AVE SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30312-3238
Mailing Address - Country:US
Mailing Address - Phone:404-577-7084
Mailing Address - Fax:
Practice Address - Street 1:1525 CLIFTON RD NE
Practice Address - Street 2:SUITE 207
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-4200
Practice Address - Country:US
Practice Address - Phone:404-778-4451
Practice Address - Fax:404-778-4355
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA001773363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant