Provider Demographics
NPI:1013912575
Name:COFFMAN, KATHLEEN M (PA)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:COFFMAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:15631 EDEN ST
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92683-6828
Mailing Address - Country:US
Mailing Address - Phone:714-898-1855
Mailing Address - Fax:
Practice Address - Street 1:19066 MAGNOLIA ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92646-2232
Practice Address - Country:US
Practice Address - Phone:714-968-0068
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15569363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP82856Medicare UPIN