Basic Information
| Provider Information | |||||||||
| NPI: | 1639354509 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOKE | ||||||||
| FirstName: | MARISA | ||||||||
| MiddleName: | P. | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22 W UNDERWOOD ST | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328061110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076483800 | ||||||||
| FaxNumber: | 4074255203 | ||||||||
| Practice Location | |||||||||
| Address1: | 22 W UNDERWOOD ST | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328061110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076483800 | ||||||||
| FaxNumber: | 4074255203 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2008 | ||||||||
| LastUpdateDate: | 06/20/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA9104877 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | 085.003112 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | PA9104877 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | PA9104877 | 01 | FL | MEDICAL LICENSE | OTHER | 009120300 | 05 | FL | MEDICAID |