Provider Demographics
NPI:1700222056
Name:COLEMAN, GREGORY WATSON (LAC)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:WATSON
Last Name:COLEMAN
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 NEWPORT LANDING DR
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94949-8214
Mailing Address - Country:US
Mailing Address - Phone:415-497-2411
Mailing Address - Fax:
Practice Address - Street 1:56 NEWPORT LANDING DR
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94949-8214
Practice Address - Country:US
Practice Address - Phone:415-497-2411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-14
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC15233171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist