Basic Information
| Provider Information | |||||||||
| NPI: | 1003535733 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | COLTRAIN | ||||||||
| FirstName: | CASSIDY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 764 | ||||||||
| Address2: | |||||||||
| City: | MEAD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805420764 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3601 4TH ST STOP 8182 | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794308182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067432981 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2022 | ||||||||
| LastUpdateDate: | 10/07/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367H00000X | 32698256 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant | 367H00000X | N | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
No ID Information.