Provider Demographics
NPI:1235146945
Name:COOTS, JOEL WAYNE (MPAS,PA-C)
Entity type:Individual
Prefix:MR
First Name:JOEL
Middle Name:WAYNE
Last Name:COOTS
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Gender:M
Credentials:MPAS,PA-C
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Mailing Address - Street 1:58 TOLSTOY TRL
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-8937
Mailing Address - Country:US
Mailing Address - Phone:219-707-5443
Mailing Address - Fax:219-707-5443
Practice Address - Street 1:2301 N BENDIX DR
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46628-3486
Practice Address - Country:US
Practice Address - Phone:574-647-1675
Practice Address - Fax:574-232-5595
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2015-11-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN10001120A363A00000X
363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN264430277Medicare PIN