Provider Demographics
NPI:1376591065
Name:COULTER, WILLIAM C (PA-C)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:C
Last Name:COULTER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:CHUCK
Other - Middle Name:
Other - Last Name:COULTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-9219
Mailing Address - Fax:239-343-9221
Practice Address - Street 1:12600 CREEKSIDE LN STE 6
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919
Practice Address - Country:US
Practice Address - Phone:239-343-9219
Practice Address - Fax:239-343-9221
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA436363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000655589OtherANTHEM BCBS
KY000000667983OtherCOOP HEALTH ANTHEM #
KY95001442Medicaid
KY95001442Medicaid
KYP04004Medicare UPIN
KY000000667983OtherCOOP HEALTH ANTHEM #