Individual
LOIS MARLENE DISHMAN-COOPER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MPAS, PA-C
Contact information
Practice address
929 STACEY BURK DR, FLORA, IL 62839-3241
(618) 662-2131
(618) 662-3077
Mailing address
929 STACEY BURK DR, FLORA, IL 62839-3241
(618) 662-2131
(618) 662-3077
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
085-002930
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
00004500
PA PRESCRIBER NUMBER
FL
01
—
085-002930
LICENSE NUMBER
IL
05
—
291816100
—
FL
01
—
MED-PAC-LIC-26883
STATE LICENSE
MT
01
—
PA9101866
PA LICENSE NUMBER
FL
Enumeration date
10/26/2006
Last updated
03/07/2023
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