Healthcare Provider Details

I. General information

NPI: 1538135926
Provider Name (Legal Business Name): JASON G COISMAN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2006
Last Update Date: 09/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

744 S WEBSTER AVE
GREEN BAY WI
54301-3505
US

IV. Provider business mailing address

6400 INDUSTRIAL LOOP
GREENDALE WI
53129-2452
US

V. Phone/Fax

Practice location:
  • Phone: 920-433-3500
  • Fax: 920-433-7932
Mailing address:
  • Phone: 414-423-4100
  • Fax: 414-423-4134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036-113102
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: