Provider Demographics
NPI:1811121403
Name:COAN, KATHRYN ELISE (MD)
Entity type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:ELISE
Last Name:COAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 33269
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85067-3269
Mailing Address - Country:US
Mailing Address - Phone:602-406-4786
Mailing Address - Fax:916-636-4358
Practice Address - Street 1:500 W THOMAS RD STE 400
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4238
Practice Address - Country:US
Practice Address - Phone:602-406-3874
Practice Address - Fax:602-406-2335
Is Sole Proprietor?:No
Enumeration Date:2009-05-11
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ43314208600000X, 208600000X
WI63910208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1811121403Medicaid
AZ161961Medicaid