1689450496 NPI number — JONATHAN MATTHEW COFER PA STUDENT

Table of content: JONATHAN MATTHEW COFER PA STUDENT (NPI 1689450496)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689450496 NPI number — JONATHAN MATTHEW COFER PA STUDENT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COFER
Provider First Name:
JONATHAN
Provider Middle Name:
MATTHEW
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA STUDENT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689450496
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4043 BEAUBIEN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28306-3006
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
785-375-3517
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2817 ROCK MERRITT AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT BRAGG
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28310-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
785-375-3517
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/06/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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