Healthcare Provider Details

I. General information

NPI: 1639170590
Provider Name (Legal Business Name): TONYA COBURN P.A.-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 06/09/2022
Certification Date: 06/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 WILSON AVE
VERSAILLES KY
40383-1947
US

IV. Provider business mailing address

460 WILSON AVE
VERSAILLES KY
40383-1947
US

V. Phone/Fax

Practice location:
  • Phone: 859-879-0111
  • Fax: 859-879-0363
Mailing address:
  • Phone: 859-879-0111
  • Fax: 859-879-0363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA452
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: