Provider Demographics
NPI:1831671445
Name:COASTAL FAMILY MEDICINE, LLC
Entity Type:Organization
Organization Name:COASTAL FAMILY MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:979-487-2135
Mailing Address - Street 1:52 WILLOW CT
Mailing Address - Street 2:
Mailing Address - City:LAKE JACKSON
Mailing Address - State:TX
Mailing Address - Zip Code:77566-4718
Mailing Address - Country:US
Mailing Address - Phone:979-824-8007
Mailing Address - Fax:
Practice Address - Street 1:230 PARKING WAY ST
Practice Address - Street 2:
Practice Address - City:LAKE JACKSON
Practice Address - State:TX
Practice Address - Zip Code:77566-5227
Practice Address - Country:US
Practice Address - Phone:979-487-2135
Practice Address - Fax:979-341-0814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-30
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty