Provider Demographics
NPI:1902022890
Name:COAST FAMILY PRACTICE
Entity Type:Organization
Organization Name:COAST FAMILY PRACTICE
Other - Org Name:ANDREW J. HENNING
Other - Org Type:Other Name
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:ROXANA
Authorized Official - Middle Name:
Authorized Official - Last Name:MATA
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:805-928-3636
Mailing Address - Street 1:607 E. PLAZA DRIVE
Mailing Address - Street 2:SUITE C201
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-6944
Mailing Address - Country:US
Mailing Address - Phone:805-928-3636
Mailing Address - Fax:805-928-3608
Practice Address - Street 1:607 PLAZA DR
Practice Address - Street 2:SUITE C201
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-6944
Practice Address - Country:US
Practice Address - Phone:805-928-3636
Practice Address - Fax:805-928-3608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty