Provider Demographics
NPI:1720171598
Name:COLEMAN, ALFRED JR (PAC)
Entity Type:Individual
Prefix:
First Name:ALFRED
Middle Name:
Last Name:COLEMAN
Suffix:JR
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:838 ANTERO CT
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95133-1202
Mailing Address - Country:US
Mailing Address - Phone:408-347-1680
Mailing Address - Fax:408-347-1681
Practice Address - Street 1:1644 ALUM ROCK AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95116-2429
Practice Address - Country:US
Practice Address - Phone:408-347-1680
Practice Address - Fax:408-347-1681
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA10187208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA10187OtherPHYSICIAN ASSISTANT LICEN