Provider Demographics
NPI:1366726994
Name:WESTERBERG, COLEY LAUREN (PA-C)
Entity type:Individual
Prefix:
First Name:COLEY
Middle Name:LAUREN
Last Name:WESTERBERG
Suffix:
Gender:F
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 1:8540 42ND AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33709-3951
Mailing Address - Country:US
Mailing Address - Phone:727-215-9295
Mailing Address - Fax:
Practice Address - Street 1:1033 MARTIN LUTHER KING STREET NORTH
Practice Address - Street 2:SUITE 108
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701
Practice Address - Country:US
Practice Address - Phone:727-215-9295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-30
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106166363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical