Provider Demographics
NPI:1457342073
Name:COBURN, DAWN (PA)
Entity Type:Individual
Prefix:MRS
First Name:DAWN
Middle Name:
Last Name:COBURN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25931 148TH DR
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11422-3001
Mailing Address - Country:US
Mailing Address - Phone:718-276-4482
Mailing Address - Fax:718-276-5083
Practice Address - Street 1:234-32 MERRICK BLVD
Practice Address - Street 2:
Practice Address - City:ROSEDALE
Practice Address - State:NY
Practice Address - Zip Code:11422
Practice Address - Country:US
Practice Address - Phone:718-376-4482
Practice Address - Fax:718-276-5083
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0040651363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYS54403Medicare UPIN