Provider Demographics
NPI:1366427767
Name:COOPER, TIMOTHY LEE (PA-C)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:LEE
Last Name:COOPER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:105 CHURCH STREET
Mailing Address - Street 2:BOX 40
Mailing Address - City:CONRAD
Mailing Address - State:IA
Mailing Address - Zip Code:50621
Mailing Address - Country:US
Mailing Address - Phone:641-366-2123
Mailing Address - Fax:641-366-2143
Practice Address - Street 1:105 CHURCH
Practice Address - Street 2:BOX 40
Practice Address - City:CONRAD
Practice Address - State:IA
Practice Address - Zip Code:50621-0040
Practice Address - Country:US
Practice Address - Phone:641-366-2123
Practice Address - Fax:641-366-2143
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IA001336363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant