Provider Demographics
NPI:1407590888
Name:COUCHMAN, GARRETT ALAN
Entity Type:Individual
Prefix:
First Name:GARRETT
Middle Name:ALAN
Last Name:COUCHMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 FOWLER AVE APT 239
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93611-0686
Mailing Address - Country:US
Mailing Address - Phone:559-593-2806
Mailing Address - Fax:
Practice Address - Street 1:1630 E HERNDON AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3391
Practice Address - Country:US
Practice Address - Phone:559-256-5200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-22
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
CA61129363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant