Provider Demographics
NPI:1326507062
Name:COULTER, LIANNE B (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:LIANNE
Middle Name:B
Last Name:COULTER
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 1:21572 OAKBROOK
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92692-3014
Mailing Address - Country:US
Mailing Address - Phone:949-677-4993
Mailing Address - Fax:
Practice Address - Street 1:29873 SANTA MARGARITA PKWY STE 100
Practice Address - Street 2:
Practice Address - City:RANCHO SANTA MARGARITA
Practice Address - State:CA
Practice Address - Zip Code:92688-3626
Practice Address - Country:US
Practice Address - Phone:949-709-0988
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-12
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15736363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant