Provider Demographics
NPI:1932165545
Name:COBURN, HEATHER L (PA-C)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:L
Last Name:COBURN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:L
Other - Last Name:KEENE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1019 W OAKLAND AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2357
Mailing Address - Country:US
Mailing Address - Phone:423-915-5000
Mailing Address - Fax:423-915-5045
Practice Address - Street 1:1019 W OAKLAND AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604
Practice Address - Country:US
Practice Address - Phone:423-915-5000
Practice Address - Fax:423-915-5045
Is Sole Proprietor?:No
Enumeration Date:2006-04-22
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA01205363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1932165545Medicaid
TNQ003283Medicaid
TN103I974754Medicare PIN
TN3709285Medicare UPIN
TN3662829Medicare PIN