Provider Demographics
NPI:1942259395
Name:COUGHLIN, CHRISTINA C (PA)
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:C
Last Name:COUGHLIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5719 WIDEWATERS PKWY
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13214-1985
Mailing Address - Country:US
Mailing Address - Phone:315-703-3480
Mailing Address - Fax:315-703-3481
Practice Address - Street 1:5496 E TAFT RD
Practice Address - Street 2:
Practice Address - City:N SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13212-3784
Practice Address - Country:US
Practice Address - Phone:315-552-6700
Practice Address - Fax:315-552-6701
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007925-1363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYPA1366Medicare ID - Type Unspecified
NYP26611Medicare UPIN