Provider Demographics
NPI:1730164617
Name:COATES, JACQUELYN ANDREA (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:ANDREA
Last Name:COATES
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:ANDREA
Other - Last Name:CANTU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHYSICIAN ASSISTANT
Mailing Address - Street 1:601 TEXAN TRAIL
Mailing Address - Street 2:STE. 300
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78411-2549
Mailing Address - Country:US
Mailing Address - Phone:361-854-0811
Mailing Address - Fax:361-806-5040
Practice Address - Street 1:601 TEXAN TRAIL
Practice Address - Street 2:STE. 300
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-2549
Practice Address - Country:US
Practice Address - Phone:361-854-0811
Practice Address - Fax:361-806-5040
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04397363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX442046YNNNMedicare PIN