=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407984883
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATHERINE ANNE COBURN ATC, PTA, CSCS, CMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2007
-----------------------------------------------------
Last Update Date | 10/03/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4822 N ROSEPOINT WAY
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83713-0944
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-941-1282
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 410 E ROCKINGHAM DR
-----------------------------------------------------
City | EAGLE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83616-6918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-941-1282
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------