MEDICARE: MR. TIMOTHY JOHN COFFMAN SR. 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	363AM0700X	Medical Physician Assistant	024068	NY

General Provider Information

NPI Number	:	1255308268
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TIMOTHY JOHN COFFMAN SR. PA-C

Provider Business Mailing Address
First Line	:	904 BLUEBIRD HILL AVE
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89084-2548
Country	:	US
Telephone Number	:	719-337-6095
Fax Number	:

Provider Business Practice Location Address
First Line	:	6900 NORTH PECOS RD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89084
Country	:	US
Telephone Number	:	702-719-9000
Fax Number	:	702-791-9359

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

Provider Enumeration Date	:	03/08/2006
Last Update Date	:	07/07/2023

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