Provider Demographics
NPI:1336457522
Name:COYLE, JULIE GAUTHIER (PA-C)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:GAUTHIER
Last Name:COYLE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:MARIE
Other - Last Name:GAUTHIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:30 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-1915
Mailing Address - Country:US
Mailing Address - Phone:315-406-1214
Mailing Address - Fax:
Practice Address - Street 1:30 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-1915
Practice Address - Country:US
Practice Address - Phone:315-406-1214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-22
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00399400363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant