Provider Demographics
NPI:1316167679
Name:COOPER, LAURA BETH (MD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:BETH
Last Name:COOPER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1148
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-1148
Mailing Address - Country:US
Mailing Address - Phone:901-569-5690
Mailing Address - Fax:
Practice Address - Street 1:260 N MILLWARD ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8581
Practice Address - Country:US
Practice Address - Phone:307-699-3115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-27
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-133662086S0122X
WY10610A208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4270994OtherBCBS TN
TN103I248692Medicare PIN