Provider Demographics
NPI:1053144352
Name:COOP, TINA
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:COOP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1570 WHEYFIELD DR
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21701-2511
Mailing Address - Country:US
Mailing Address - Phone:240-586-1903
Mailing Address - Fax:
Practice Address - Street 1:74 THOMAS JOHNSON DR
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4501
Practice Address - Country:US
Practice Address - Phone:301-694-9033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-22
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR243396363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily