Provider Demographics
NPI:1891295663
Name:COULAM, MICHAEL JOSEPH
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:COULAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4050 FLINTLOCK DR
Mailing Address - Street 2:
Mailing Address - City:WINNEMUCCA
Mailing Address - State:NV
Mailing Address - Zip Code:89445-8651
Mailing Address - Country:US
Mailing Address - Phone:775-217-9903
Mailing Address - Fax:
Practice Address - Street 1:4050 FLINTLOCK DR
Practice Address - Street 2:
Practice Address - City:WINNEMUCCA
Practice Address - State:NV
Practice Address - Zip Code:89445-8651
Practice Address - Country:US
Practice Address - Phone:775-217-9903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-17
Last Update Date:2018-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV$$$$$$$$$Medicaid