MEDICARE: MR. BRADLEY PHILIP COUGHLIN PA-C

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	363AS0400X	Surgical Physician Assistant	0110002173	VA
2	363AM0700X	Medical Physician Assistant	2850	CO

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	P00306338	OTHER	VA	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	TN0141	OTHER	VA	JOHN DEERE HEALTH
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053399451
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRADLEY PHILIP COUGHLIN PA-C

Provider Business Mailing Address
First Line	:	1650 COCHRANE CIR BLDG 7505
Second Line	:	CREDENTIALS OFFICE RM # 163
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80913-4613
Country	:	US
Telephone Number	:	719-526-2092
Fax Number	:	719-526-7732

Provider Business Practice Location Address
First Line	:	2767 JANITELL RD
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80906-4102
Country	:	US
Telephone Number	:	719-365-2888
Fax Number	:

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

Provider Enumeration Date	:	01/05/2006
Last Update Date	:	05/12/2020

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