Healthcare Provider Details

I. General information

NPI: 1326507062
Provider Name (Legal Business Name): LIANNE B COULTER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2019
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26991 CROWN VALLEY PKWY STE 100
MISSION VIEJO CA
92691-6511
US

IV. Provider business mailing address

PO BOX 35380
LAS VEGAS NV
89133-5380
US

V. Phone/Fax

Practice location:
  • Phone: 949-582-5430
  • Fax: 949-348-9513
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number15736
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: