MEDICARE: KELLY S COYNE PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA52493	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PA52493	OTHER	CA	LICENSE

General Provider Information

NPI Number	:	1235142977
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY S COYNE PA-C

Provider Business Mailing Address
First Line	:	4791 E PALM CANYON DR
Second Line	:	SUITE 200
City	:	PALM SPRINGS
State	:	CA
Zip	:	92264-5220
Country	:	US
Telephone Number	:	760-834-7950
Fax Number	:

Provider Business Practice Location Address
First Line	:	4791 E PALM CANYON DR
Second Line	:	SUITE 200
City	:	PALM SPRINGS
State	:	CA
Zip	:	92264-5220
Country	:	US
Telephone Number	:	760-834-7950
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/14/2006
Last Update Date	:	04/05/2016

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