Provider Demographics
NPI:1669684205
Name:COFFEY, MARGO R (PA-C)
Entity Type:Individual
Prefix:
First Name:MARGO
Middle Name:R
Last Name:COFFEY
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 1:6 LINCOLN RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06385-3312
Mailing Address - Country:US
Mailing Address - Phone:860-444-3366
Mailing Address - Fax:
Practice Address - Street 1:365 MONTAUK AVE
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4700
Practice Address - Country:US
Practice Address - Phone:860-442-0711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000015363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4041679Medicaid
CT4024972Medicaid
CT4041679Medicaid
CT4041679Medicaid