Provider Demographics
NPI:1003535733
Name:COLTRAIN, CASSIDY
Entity Type:Individual
Prefix:
First Name:CASSIDY
Middle Name:
Last Name:COLTRAIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 764
Mailing Address - Street 2:
Mailing Address - City:MEAD
Mailing Address - State:CO
Mailing Address - Zip Code:80542-0764
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3601 4TH ST STOP 8182
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79430-8182
Practice Address - Country:US
Practice Address - Phone:806-743-2981
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-25
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32698256367H00000X
367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant