Provider Demographics
NPI:1124728779
Name:COOPER, CHARLES DERICK (NP)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:DERICK
Last Name:COOPER
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4224 VZ COUNTY ROAD 2112
Mailing Address - Street 2:
Mailing Address - City:WILLS POINT
Mailing Address - State:TX
Mailing Address - Zip Code:75169-7786
Mailing Address - Country:US
Mailing Address - Phone:903-594-8309
Mailing Address - Fax:
Practice Address - Street 1:126 W MAIN ST
Practice Address - Street 2:
Practice Address - City:GUN BARREL CITY
Practice Address - State:TX
Practice Address - Zip Code:75156-5403
Practice Address - Country:US
Practice Address - Phone:903-887-1092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-02
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1112062363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily