Provider Demographics
NPI:1053399451
Name:COUGHLIN, BRADLEY PHILIP (PA-C)
Entity type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:PHILIP
Last Name:COUGHLIN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 COCHRANE CIR BLDG 7505
Mailing Address - Street 2:CREDENTIALS OFFICE RM # 163
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80913-4613
Mailing Address - Country:US
Mailing Address - Phone:719-526-2092
Mailing Address - Fax:719-526-7732
Practice Address - Street 1:2767 JANITELL RD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-4102
Practice Address - Country:US
Practice Address - Phone:719-365-2888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002173363AS0400X
CO2850363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VATN0141OtherJOHN DEERE HEALTH
VA010213355Medicaid
VAP00306338OtherRAILROAD MEDICARE
009102R04Medicare ID - Type Unspecified
P82737Medicare UPIN
COCOA100433Medicare PIN