Provider Demographics
NPI:1346456555
Name:COUGHLAN, JOHN FRANCIS (PA C)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:FRANCIS
Last Name:COUGHLAN
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 1:6910 CORKSCREW LANE
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34120
Mailing Address - Country:US
Mailing Address - Phone:239-595-7667
Mailing Address - Fax:
Practice Address - Street 1:4550 EXECUTIVE DR
Practice Address - Street 2:SUITE 104
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34119-8805
Practice Address - Country:US
Practice Address - Phone:239-217-4434
Practice Address - Fax:239-217-4436
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2010-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102717363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL292945700Medicaid
FLE2690XMedicare ID - Type Unspecified
FL292945700Medicaid