Provider Demographics
NPI:1457386690
Name:COBURN, BRENT A (MSPT)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:A
Last Name:COBURN
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11711 NE 12TH ST
Mailing Address - Street 2:3 A
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98005-2461
Mailing Address - Country:US
Mailing Address - Phone:425-450-9474
Mailing Address - Fax:425-452-0704
Practice Address - Street 1:13127 121ST WAY NE
Practice Address - Street 2:F
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-3051
Practice Address - Country:US
Practice Address - Phone:425-823-8631
Practice Address - Fax:425-814-4731
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAPT00007127225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7060338Medicaid
WA116537OtherL & I