Basic Information
| Provider Information | |||||||||
| NPI: | 1083658546 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLEMAN | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1501 E MOCKINGBIRD LN STE 101 | ||||||||
| Address2: | |||||||||
| City: | VICTORIA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 779042178 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3615736291 | ||||||||
| FaxNumber: | 3615762434 | ||||||||
| Practice Location | |||||||||
| Address1: | 815 N VIRGINIA ST | ||||||||
| Address2: | |||||||||
| City: | PORT LAVACA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 77979 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3615736291 | ||||||||
| FaxNumber: | 3615762434 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 08/28/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 52733 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 165728002 | 05 | TX | MEDICAID |