Basic Information
| Provider Information | |||||||||
| NPI: | 1639158330 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOPER | ||||||||
| FirstName: | KRISTINE | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9200 W WISCONSIN AVE | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532263522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4148056850 | ||||||||
| FaxNumber: | 4148056851 | ||||||||
| Practice Location | |||||||||
| Address1: | 9200 W WISCONSIN AVE | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532263522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4148056850 | ||||||||
| FaxNumber: | 4148056851 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2006 | ||||||||
| LastUpdateDate: | 03/28/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 41561-021 | WI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 30093500 | 05 | WI | MEDICAID | 1639158330 | 05 | WI | MEDICAID |