Provider Demographics
NPI:1639155690
Name:COFFEY, ANTHONY NELSON (PT)
Entity type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:NELSON
Last Name:COFFEY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:MR
Other - First Name:NELSON
Other - Middle Name:
Other - Last Name:COFFEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:8170 33RD AVE S # MS 21110Q
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1500 CURVE CREST BLVD W
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-6040
Practice Address - Country:US
Practice Address - Phone:651-439-1234
Practice Address - Fax:651-275-3325
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5790225100000X
NC1763225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40344100Medicaid
P00283601Medicare PIN
MN650001316Medicare PIN