Provider Demographics
NPI:1174853634
Name:COOPER, MICHELE (RPA-C)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:COOPER
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 PROFFESSIONAL PARK RD
Mailing Address - Street 2:
Mailing Address - City:STORRS
Mailing Address - State:CT
Mailing Address - Zip Code:06268-1659
Mailing Address - Country:US
Mailing Address - Phone:860-487-0002
Mailing Address - Fax:860-429-1663
Practice Address - Street 1:34 PROFFESSIONAL PARK RD
Practice Address - Street 2:
Practice Address - City:STORRS MANSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06268-1659
Practice Address - Country:US
Practice Address - Phone:860-487-0002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003581363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN6021501OtherBLUECROSS BLUESHIELD
TNP01455819OtherRR MEDICARE
TN9213744OtherAETNA
TNQ006875Medicaid
TN9213744OtherAETNA