Provider Demographics
NPI:1528163995
Name:COOPER, CHRISTOPHER J (PA-C)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:J
Last Name:COOPER
Suffix:
Gender:M
Credentials:PA-C
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 124
Mailing Address - Street 2:
Mailing Address - City:EMINENCE
Mailing Address - State:KY
Mailing Address - Zip Code:40019-0124
Mailing Address - Country:US
Mailing Address - Phone:502-845-6288
Mailing Address - Fax:502-222-0029
Practice Address - Street 1:151 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:EMINENCE
Practice Address - State:KY
Practice Address - Zip Code:40019-1149
Practice Address - Country:US
Practice Address - Phone:502-845-6288
Practice Address - Fax:502-222-0029
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA909363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q53197Medicare UPIN
KY0236447Medicare PIN