Provider Demographics
NPI:1972685683
Name:COLEMAN, MATTHEW TYNES (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:TYNES
Last Name:COLEMAN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2539 VIKING DR STE 101
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-2165
Mailing Address - Country:US
Mailing Address - Phone:318-925-3338
Mailing Address - Fax:318-747-8150
Practice Address - Street 1:2539 VIKING DR STE 101
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-2165
Practice Address - Country:US
Practice Address - Phone:318-747-8100
Practice Address - Fax:318-747-8150
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA.A10348363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA57561P679Medicare ID - Type UnspecifiedMEDICARE