Provider Demographics
NPI:1962683623
Name:COAST NURSE PRACTITIONERS, INC
Entity Type:Organization
Organization Name:COAST NURSE PRACTITIONERS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:228-826-4600
Mailing Address - Street 1:PO BOX 5386
Mailing Address - Street 2:
Mailing Address - City:VANCLEAVE
Mailing Address - State:MS
Mailing Address - Zip Code:39565-5386
Mailing Address - Country:US
Mailing Address - Phone:228-826-4600
Mailing Address - Fax:228-392-8393
Practice Address - Street 1:13300 RS KIMBALL RD
Practice Address - Street 2:
Practice Address - City:VANCLEAVE
Practice Address - State:MS
Practice Address - Zip Code:39565-7235
Practice Address - Country:US
Practice Address - Phone:228-826-4600
Practice Address - Fax:228-392-8393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-21
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR851501363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00126136Medicaid
MSP20213Medicare UPIN
MS00126136Medicaid