Provider Demographics
NPI:1386836278
Name:COUGHLIN, KIERAN M (PA)
Entity Type:Individual
Prefix:
First Name:KIERAN
Middle Name:M
Last Name:COUGHLIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7140 PORT SYLVANIA DR
Mailing Address - Street 2:#600
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43617-1176
Mailing Address - Country:US
Mailing Address - Phone:419-843-8178
Mailing Address - Fax:419-843-8698
Practice Address - Street 1:2142 N COVE BLVD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-3895
Practice Address - Country:US
Practice Address - Phone:419-291-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-14
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50002597363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant