Provider Demographics
NPI:1841300985
Name:COBURN, NANCY JO (MD)
Entity type:Individual
Prefix:
First Name:NANCY JO
Middle Name:
Last Name:COBURN
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 1:5900 COYLE AVE STE A
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-0400
Mailing Address - Country:US
Mailing Address - Phone:916-332-1210
Mailing Address - Fax:916-332-0207
Practice Address - Street 1:5900 COYLE AVENUE
Practice Address - Street 2:#A
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-0429
Practice Address - Country:US
Practice Address - Phone:916-332-1210
Practice Address - Fax:916-332-0207
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG55195207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1841300985OtherNPI
CA00G551950Medicaid
CA00G551950Medicare PIN
CA1841300985OtherNPI