MEDICARE: KATHLEEN M COFFMAN PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PA15569	CA

General Provider Information

NPI Number	:	1013912575
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN M COFFMAN PA

Provider Business Mailing Address
First Line	:	15631 EDEN ST
Second Line	:
City	:	WESTMINSTER
State	:	CA
Zip	:	92683-6828
Country	:	US
Telephone Number	:	714-898-1855
Fax Number	:

Provider Business Practice Location Address
First Line	:	19066 MAGNOLIA ST
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92646-2232
Country	:	US
Telephone Number	:	714-968-0068
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/20/2005
Last Update Date	:	11/29/2021

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