Basic Information
| Provider Information | |||||||||
| NPI: | 1750377479 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOPER | ||||||||
| FirstName: | KATHRYN | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 E GENESEE ST | ||||||||
| Address2: | STE 300 | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132101892 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154711044 | ||||||||
| FaxNumber: | 3154744312 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 E GENESEE ST | ||||||||
| Address2: | STE 300 | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132101892 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154711044 | ||||||||
| FaxNumber: | 3154744312 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2005 | ||||||||
| LastUpdateDate: | 11/09/2010 | ||||||||
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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 | 207QA0505X | F331842 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine | 363L00000X | F331842 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LA2200X | F331842 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 02054626 | 05 | NY | MEDICAID |