Provider Demographics
NPI:1497838478
Name:COOK, JAMES LEE (PA-C)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:LEE
Last Name:COOK
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 1:1975 MARTHA AVE
Mailing Address - Street 2:STE A
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7580
Mailing Address - Country:US
Mailing Address - Phone:208-522-6930
Mailing Address - Fax:208-523-5342
Practice Address - Street 1:1975 MARTHA AVE
Practice Address - Street 2:STE A
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7580
Practice Address - Country:US
Practice Address - Phone:208-522-6930
Practice Address - Fax:208-523-5342
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2015-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA460207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPAHR4OtherBLUE CROSS
ID000060000Medicaid
ID10144509OtherBLUE SHIELD
ID000060000Medicaid
IDPAHR4OtherBLUE CROSS