Basic Information
| Provider Information | |||||||||
| NPI: | 1053399451 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COUGHLIN | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | PHILIP | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1650 COCHRANE CIR BLDG 7505 | ||||||||
| Address2: | CREDENTIALS OFFICE RM # 163 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809134613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195262092 | ||||||||
| FaxNumber: | 7195267732 | ||||||||
| Practice Location | |||||||||
| Address1: | 2767 JANITELL RD | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809064102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193652888 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2006 | ||||||||
| LastUpdateDate: | 05/12/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 0110002173 | VA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AM0700X | 2850 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | TN0141 | 01 | VA | JOHN DEERE HEALTH | OTHER | 010213355 | 05 | VA | MEDICAID | P00306338 | 01 | VA | RAILROAD MEDICARE | OTHER |