Basic Information
| Provider Information | |||||||||
| NPI: | 1003153628 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLEMAN | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | FNP-BC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | COLEMAN | ||||||||
| OtherFirstName: | LONNIE | ||||||||
| OtherMiddleName: | RICHARD | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | FNP-BC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2112 W UNIVERSITY DR. 340 | ||||||||
| Address2: | |||||||||
| City: | EDINBURG | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9568785409 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 128 N. FM 3167 | ||||||||
| Address2: | |||||||||
| City: | RIO GRANDE CITY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78582 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9564870453 | ||||||||
| FaxNumber: | 9564876190 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2013 | ||||||||
| LastUpdateDate: | 10/12/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 685397 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 332242204 | 05 | TX | MEDICAID |