Provider Demographics
NPI:1700850997
Name:COUGHLIN, MARTIN W (CRNA)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:W
Last Name:COUGHLIN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2854 HIGHWAY 55
Mailing Address - Street 2:SUITE 130
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55121
Mailing Address - Country:US
Mailing Address - Phone:651-224-4930
Mailing Address - Fax:651-842-3391
Practice Address - Street 1:393 DUNLAP ST
Practice Address - Street 2:
Practice Address - City:ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104
Practice Address - Country:US
Practice Address - Phone:651-602-7245
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR0887281367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN936343200Medicaid
MN936343200Medicaid