Provider Demographics
NPI:1043087224
Name:COOPER, MATTHEW DAVID (APRN)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:DAVID
Last Name:COOPER
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 WAHOO AVE
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06349-2324
Mailing Address - Country:US
Mailing Address - Phone:860-694-4123
Mailing Address - Fax:
Practice Address - Street 1:1 WAHOO AVE
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06349-2324
Practice Address - Country:US
Practice Address - Phone:860-694-4123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-07
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95028254363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily