Provider Demographics
NPI:1164020830
Name:COBURN, ABBEY (PA-C)
Entity Type:Individual
Prefix:
First Name:ABBEY
Middle Name:
Last Name:COBURN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6028 S RIDGELINE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84405-6906
Mailing Address - Country:US
Mailing Address - Phone:801-917-8500
Mailing Address - Fax:
Practice Address - Street 1:6028 S RIDGELINE DR STE 200
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-6906
Practice Address - Country:US
Practice Address - Phone:801-917-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-14
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11819270-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant