Basic Information
| Provider Information | |||||||||
| NPI: | 1023044047 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COBERLY | ||||||||
| FirstName: | MARSHA | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | CFNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1955 YORK AVE | ||||||||
| Address2: | |||||||||
| City: | CANON CITY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812128627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7192691708 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1338 PHAY AVE | ||||||||
| Address2: | ST THOMAS MORE HOSPITAL | ||||||||
| City: | CANON CITY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 81212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7192852000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2006 | ||||||||
| LastUpdateDate: | 09/09/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | NP-3511 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 56158564 | 05 | CO | MEDICAID |