Provider Demographics
NPI:1689747883
Name:COLEMAN, ROGER RYAN (DC)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:RYAN
Last Name:COLEMAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 564
Mailing Address - Street 2:
Mailing Address - City:OTHELLO
Mailing Address - State:WA
Mailing Address - Zip Code:99344-0564
Mailing Address - Country:US
Mailing Address - Phone:509-488-9679
Mailing Address - Fax:509-488-9670
Practice Address - Street 1:1344 E MAIN STREET
Practice Address - Street 2:
Practice Address - City:OTHELLO
Practice Address - State:WA
Practice Address - Zip Code:99344-1559
Practice Address - Country:US
Practice Address - Phone:509-488-9679
Practice Address - Fax:509-488-9670
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00001013111N00000X
WY300111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2212306Medicaid
WA14322OtherDEPT OF L & I
T02266Medicare UPIN