Provider Demographics
NPI:1679146732
Name:COOK, SAMUEL ANNIBALE (PA-C)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:ANNIBALE
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 1:6737 OLD WATERLOO RD APT 114
Mailing Address - Street 2:
Mailing Address - City:ELKRIDGE
Mailing Address - State:MD
Mailing Address - Zip Code:21075-7114
Mailing Address - Country:US
Mailing Address - Phone:503-758-4931
Mailing Address - Fax:
Practice Address - Street 1:4701 MELBOURNE PL
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:MD
Practice Address - Zip Code:20740-2540
Practice Address - Country:US
Practice Address - Phone:301-345-4400
Practice Address - Fax:301-345-4200
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-19
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0008045363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDC0008045OtherMARYLAND BOARD OF PHYSICIANS
1169827OtherNCCPA