Provider Demographics
NPI:1083125017
Name:COFFMAN, ELIZABETH THERESE (PA-C)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:THERESE
Last Name:COFFMAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:THERESE
Other - Last Name:KREAGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LLMSW
Mailing Address - Street 1:400 SHADOW LN
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-4363
Mailing Address - Country:US
Mailing Address - Phone:702-805-2069
Mailing Address - Fax:
Practice Address - Street 1:400 SHADOW LN
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4363
Practice Address - Country:US
Practice Address - Phone:702-805-2069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-17
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68020897611041C0700X
NVPA2844363AM0700X
MI5601010553363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVPA2844OtherPHYSICIAN ASSISTANT LICENSE