Healthcare Provider Details

I. General information

NPI: 1376517136
Provider Name (Legal Business Name): MARK J. COYLE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2006
Last Update Date: 09/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 POMFRET ST
PUTNAM CT
06260-1836
US

IV. Provider business mailing address

PO BOX 409010
ATLANTA GA
30384-9010
US

V. Phone/Fax

Practice location:
  • Phone: 860-928-6541
  • Fax: 860-963-6368
Mailing address:
  • Phone: 800-377-8721
  • Fax: 304-523-2241

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number000683
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: