Provider Demographics
NPI:1194199349
Name:COFFMAN, JAKE ANDREW (PA-C)
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:ANDREW
Last Name:COFFMAN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:190 KIMEL PARK DR STE 140
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-6946
Practice Address - Country:US
Practice Address - Phone:336-277-2225
Practice Address - Fax:336-277-2231
Is Sole Proprietor?:No
Enumeration Date:2015-11-25
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC0010-06081363A00000X
NC001006081363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant