Healthcare Provider Details

I. General information

NPI: 1396202388
Provider Name (Legal Business Name): MATTHEW COLEMAN RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2019
Last Update Date: 02/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 HOSPITAL WAY
POCATELLO ID
83201-2745
US

IV. Provider business mailing address

444 HOSPITAL WAY
POCATELLO ID
83201-2745
US

V. Phone/Fax

Practice location:
  • Phone: 208-547-5038
  • Fax:
Mailing address:
  • Phone: 208-235-4263
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number38259
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: