Provider Demographics
NPI:1396961140
Name:COLEMAN, TAMRA J (PT)
Entity type:Individual
Prefix:
First Name:TAMRA
Middle Name:J
Last Name:COLEMAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1977 ACOMA BLVD W
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-2958
Mailing Address - Country:US
Mailing Address - Phone:928-302-5323
Mailing Address - Fax:
Practice Address - Street 1:1977 ACOMA BLVD W
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-2958
Practice Address - Country:US
Practice Address - Phone:928-302-5323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00002692225100000X
OR4732225100000X
CA25961225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR523039028OtherREGENCE BCBS
OR274430Medicaid
OR274430Medicaid