Basic Information
| Provider Information | |||||||||
| NPI: | 1780612291 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOKE | ||||||||
| FirstName: | NELSON | ||||||||
| MiddleName: | ROGER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | COOKE | ||||||||
| OtherFirstName: | N. | ||||||||
| OtherMiddleName: | ROGER | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 421 | ||||||||
| Address2: | |||||||||
| City: | LIBERTY LAKE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 990190421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8667472455 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 212 E CENTRAL | ||||||||
| Address2: | STE 440 | ||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 99208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5092529602 | ||||||||
| FaxNumber: | 5097899031 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 10/15/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | MD00014697 | WA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 268 | 01 | GROUP HEALTH | OTHER | 35-9723 | 05 | MT | MEDICAID | 4853935 | 05 | CA | MEDICAID | 003168000 | 05 | ID | MEDICAID | 907228400 | 05 | FL | MEDICAID | 1046101 | 05 | WA | MEDICAID | KA634 | 01 | BLUE CROSS OF IDAHO | OTHER | AB32999 | 01 | WA | MDC GROUP | OTHER | 31509 | 01 | WA | LABOR AND INDUSTRIES | OTHER | E01203 | 01 | ASURIS | OTHER |