Provider Demographics
NPI:1821018557
Name:COATES, THEODORE W (PA-C)
Entity Type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:W
Last Name:COATES
Suffix:
Gender:M
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 1:2031 ANDERSON RD
Mailing Address - Street 2:STE A
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-0621
Mailing Address - Country:US
Mailing Address - Phone:530-757-3700
Mailing Address - Fax:530-756-6907
Practice Address - Street 1:2031 ANDERSON RD
Practice Address - Street 2:STE A
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-0621
Practice Address - Country:US
Practice Address - Phone:530-757-3700
Practice Address - Fax:530-756-6907
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA11101363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
R57454Medicare UPIN
CA0PA111010Medicare ID - Type Unspecified