1700850997 NPI number — MARTIN W COUGHLIN CRNA

Table of content: MS. XIMENA ABONDANO RN LMHC (NPI 1861751752)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700850997 NPI number — MARTIN W COUGHLIN CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COUGHLIN
Provider First Name:
MARTIN
Provider Middle Name:
W
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
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:
1700850997
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/31/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2854 HIGHWAY 55
Provider Second Line Business Mailing Address:
SUITE 130
Provider Business Mailing Address City Name:
EAGAN
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55121
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-224-4930
Provider Business Mailing Address Fax Number:
651-842-3391

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
393 DUNLAP ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-602-7245
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/14/2006

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: 367500000X , with the licence number:  R0887281 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 936343200 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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