Provider Demographics
NPI:1205847290
Name:COBURN, RODRICK LASHONN (PA-C)
Entity Type:Individual
Prefix:
First Name:RODRICK
Middle Name:LASHONN
Last Name:COBURN
Suffix:
Gender:M
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 1:11445 GHIBERTI WAY
Mailing Address - Street 2:
Mailing Address - City:PORTER RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:91326-4084
Mailing Address - Country:US
Mailing Address - Phone:818-422-2595
Mailing Address - Fax:
Practice Address - Street 1:11445 GHIBERTI WAY
Practice Address - Street 2:
Practice Address - City:PORTER RANCH
Practice Address - State:CA
Practice Address - Zip Code:91326-4084
Practice Address - Country:US
Practice Address - Phone:818-422-2595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18361363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant