Basic Information
| Provider Information | |||||||||
| NPI: | 1285105882 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COULTER | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | GREGORY | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | AGACNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3241 WESTERN BRANCH BLVD | ||||||||
| Address2: | STE A | ||||||||
| City: | CHESAPEAKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 233215260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7576863508 | ||||||||
| FaxNumber: | 7576860541 | ||||||||
| Practice Location | |||||||||
| Address1: | 736 BATTLEFIELD BLVD N | ||||||||
| Address2: | |||||||||
| City: | CHESAPEAKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 233204941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573128121 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2018 | ||||||||
| LastUpdateDate: | 12/31/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 0024176712 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.