Healthcare Provider Details

I. General information

NPI: 1679684401
Provider Name (Legal Business Name): JONATHAN W COGGESHALL JR. P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27 MILL ST
WALDOBORO ME
04572-6013
US

IV. Provider business mailing address

27 MILL ST
WALDOBORO ME
04572-6013
US

V. Phone/Fax

Practice location:
  • Phone: 207-832-5291
  • Fax:
Mailing address:
  • Phone: 207-832-5291
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-459
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: