Provider Demographics
NPI:1710982574
Name:COENEN, KATHLEEN DIANE (PA)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:DIANE
Last Name:COENEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7470 BROCKWAY RD
Mailing Address - Street 2:
Mailing Address - City:BROCKWAY
Mailing Address - State:MI
Mailing Address - Zip Code:48097-3458
Mailing Address - Country:US
Mailing Address - Phone:810-387-9355
Mailing Address - Fax:810-387-9400
Practice Address - Street 1:7470 BROCKWAY RD
Practice Address - Street 2:
Practice Address - City:BROCKWAY
Practice Address - State:MI
Practice Address - Zip Code:48097-3458
Practice Address - Country:US
Practice Address - Phone:810-387-9355
Practice Address - Fax:810-387-9400
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004200363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q02195Medicare UPIN
MIN10760006Medicare ID - Type Unspecified