Provider Demographics
NPI:1306312665
Name:COOPER, TEVANA ANN (PCA)
Entity type:Individual
Prefix:
First Name:TEVANA
Middle Name:ANN
Last Name:COOPER
Suffix:
Gender:F
Credentials:PCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2725 E EVANS AVE APT D29
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89030-5494
Mailing Address - Country:US
Mailing Address - Phone:702-517-6102
Mailing Address - Fax:
Practice Address - Street 1:3435 W CRAIG RD STE C
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032-5116
Practice Address - Country:US
Practice Address - Phone:702-538-8814
Practice Address - Fax:702-560-0488
Is Sole Proprietor?:No
Enumeration Date:2018-10-15
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV2104426457Medicaid