Basic Information
Provider Information | |||||||||
NPI: | 1932165545 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COBURN | ||||||||
FirstName: | HEATHER | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | KEENE | ||||||||
OtherFirstName: | HEATHER | ||||||||
OtherMiddleName: | L | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1019 W OAKLAND AVE | ||||||||
Address2: | SUITE 1 | ||||||||
City: | JOHNSON CITY | ||||||||
State: | TN | ||||||||
PostalCode: | 376042357 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4239155000 | ||||||||
FaxNumber: | 4239155045 | ||||||||
Practice Location | |||||||||
Address1: | 1019 W OAKLAND AVE | ||||||||
Address2: | SUITE 1 | ||||||||
City: | JOHNSON CITY | ||||||||
State: | TN | ||||||||
PostalCode: | 37604 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4239155000 | ||||||||
FaxNumber: | 4239155045 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/22/2006 | ||||||||
LastUpdateDate: | 06/04/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA01205 | TN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
ID | Type | State | Issuer | Description | 1932165545 | 05 | VA |   | MEDICAID | Q003283 | 05 | TN |   | MEDICAID |