Provider Demographics
NPI:1821039249
Name:COUGHLIN, CORINNE E (PA-C)
Entity Type:Individual
Prefix:
First Name:CORINNE
Middle Name:E
Last Name:COUGHLIN
Suffix:
Gender:F
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:PO BOX 159
Mailing Address - Street 2:
Mailing Address - City:TIOGA
Mailing Address - State:ND
Mailing Address - Zip Code:58852-0159
Mailing Address - Country:US
Mailing Address - Phone:701-664-3368
Mailing Address - Fax:701-664-3300
Practice Address - Street 1:710 N WELO ST
Practice Address - Street 2:
Practice Address - City:TIOGA
Practice Address - State:ND
Practice Address - Zip Code:58852-7117
Practice Address - Country:US
Practice Address - Phone:701-664-3368
Practice Address - Fax:701-664-3300
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC0103363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND16047OtherBCBSND
S61626Medicare UPIN
ND16047OtherBCBSND