Basic Information
Provider Information
NPI: 1598303463
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: COATNEY
FirstName: MIKE
MiddleName: LAVERNE
NamePrefix: MR.
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 187 E MONROE AVE
Address2:  
City: JAY
State: OK
PostalCode: 743462870
CountryCode: US
TelephoneNumber: 9188454096
FaxNumber:  
Practice Location
Address1: 109 N FAIRLAND ST
Address2:  
City: PRYOR
State: OK
PostalCode: 743614203
CountryCode: US
TelephoneNumber: 9188251405
FaxNumber: 9182054830
Other Information
ProviderEnumerationDate: 12/11/2019
LastUpdateDate: 12/11/2019
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 12/11/2019

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
175T00000X  Y    

No ID Information.


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