Healthcare Provider Details

I. General information

NPI: 1235146945
Provider Name (Legal Business Name): JOEL WAYNE COOTS MPAS,PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 11/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 N BENDIX DR
SOUTH BEND IN
46628-3486
US

IV. Provider business mailing address

58 TOLSTOY TRL
VALPARAISO IN
46383-8937
US

V. Phone/Fax

Practice location:
  • Phone: 574-647-1675
  • Fax: 574-232-5595
Mailing address:
  • Phone: 219-707-5443
  • Fax: 219-707-5443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10001120A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: