=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801438544
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALYSSA COLEMAN PA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/15/2019
-----------------------------------------------------
Last Update Date | 10/15/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 29995 TECHNOLOGY DR STE 202
-----------------------------------------------------
City | MURRIETA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92563-2633
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-698-1118
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6813 SAND ASTER DR
-----------------------------------------------------
City | CARLSBAD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92011-5028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-703-7056
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | PA57102
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------