Provider Demographics
NPI:1386836781
Name:COOKSEY, LANAI BAHR (PA-C)
Entity type:Individual
Prefix:
First Name:LANAI
Middle Name:BAHR
Last Name:COOKSEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LANAI
Other - Middle Name:K
Other - Last Name:BAHR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:6890 BELFORT OAKS PL
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-6241
Mailing Address - Country:US
Mailing Address - Phone:904-293-1313
Mailing Address - Fax:904-296-4205
Practice Address - Street 1:6890 BELFORT OAKS PL
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-6241
Practice Address - Country:US
Practice Address - Phone:904-293-1313
Practice Address - Fax:904-296-4205
Is Sole Proprietor?:No
Enumeration Date:2007-08-10
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102867363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDO249XMedicare PIN
FLP00885769Medicare PIN