Provider Demographics
NPI:1649533035
Name:COGHLAN, CASSANDRA LEE (PA-C)
Entity type:Individual
Prefix:MS
First Name:CASSANDRA
Middle Name:LEE
Last Name:COGHLAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:LEE
Other - Middle Name:
Other - Last Name:COGHLAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:960 JOHNSON FERRY RD
Mailing Address - Street 2:STE 940
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1631
Mailing Address - Country:US
Mailing Address - Phone:404-851-6000
Mailing Address - Fax:404-252-2736
Practice Address - Street 1:960 JOHNSON FERRY RD
Practice Address - Street 2:STE 940
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1631
Practice Address - Country:US
Practice Address - Phone:404-851-6000
Practice Address - Fax:404-252-2736
Is Sole Proprietor?:No
Enumeration Date:2012-06-20
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006463363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1649533035OtherNPI NUMBER
GA003125044BMedicaid
GA003125044BMedicaid