Provider Demographics
NPI:1174558845
Name:COLEMAN, JOHNNY KEITH (PA-C)
Entity type:Individual
Prefix:
First Name:JOHNNY
Middle Name:KEITH
Last Name:COLEMAN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:K
Other - Last Name:COLEMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:3302 RENNER DR
Mailing Address - Street 2:
Mailing Address - City:FORTUNA
Mailing Address - State:CA
Mailing Address - Zip Code:95540-3120
Mailing Address - Country:US
Mailing Address - Phone:707-725-3318
Mailing Address - Fax:707-725-9396
Practice Address - Street 1:3302 RENNER DR
Practice Address - Street 2:
Practice Address - City:FORTUNA
Practice Address - State:CA
Practice Address - Zip Code:95540-7103
Practice Address - Country:US
Practice Address - Phone:707-725-3318
Practice Address - Fax:707-725-9396
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13661363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care