Provider Demographics
NPI:1154161602
Name:LEWIS, COOPER
Entity type:Individual
Prefix:
First Name:COOPER
Middle Name:
Last Name:LEWIS
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 1:1132 SE 60TH ST
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:MO
Mailing Address - Zip Code:64652-8140
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:901 S NATIONAL AVE # PROF160
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65897-0001
Practice Address - Country:US
Practice Address - Phone:417-836-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-30
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer