Healthcare Provider Details

I. General information

NPI: 1972685683
Provider Name (Legal Business Name): MATTHEW TYNES COLEMAN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 10/28/2020
Certification Date: 10/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2539 VIKING DR STE 101
BOSSIER CITY LA
71111-2165
US

IV. Provider business mailing address

2539 VIKING DR STE 101
BOSSIER CITY LA
71111-2165
US

V. Phone/Fax

Practice location:
  • Phone: 318-747-8100
  • Fax: 318-747-8150
Mailing address:
  • Phone: 318-925-3338
  • Fax: 318-747-8150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA.A10348
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: