Basic Information
| Provider Information | |||||||||
| NPI: | 1649533035 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COGHLAN | ||||||||
| FirstName: | CASSANDRA | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | COGHLAN | ||||||||
| OtherFirstName: | LEE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 960 JOHNSON FERRY RD | ||||||||
| Address2: | STE 940 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4048516000 | ||||||||
| FaxNumber: | 4042522736 | ||||||||
| Practice Location | |||||||||
| Address1: | 960 JOHNSON FERRY RD | ||||||||
| Address2: | STE 940 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4048516000 | ||||||||
| FaxNumber: | 4042522736 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2012 | ||||||||
| LastUpdateDate: | 02/01/2017 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 006463 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 006463 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 1649533035 | 01 | GA | NPI NUMBER | OTHER | 003125044B | 05 | GA | MEDICAID |