Provider Demographics
NPI:1194076208
Name:COLEMAN, JAMES G (PA-C)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:G
Last Name:COLEMAN
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 1:2717 PIPER HILLS DR
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62221-3457
Mailing Address - Country:US
Mailing Address - Phone:618-593-3764
Mailing Address - Fax:
Practice Address - Street 1:18209 EULA MAE PKWY
Practice Address - Street 2:
Practice Address - City:CARLYLE
Practice Address - State:IL
Practice Address - Zip Code:62231-6407
Practice Address - Country:US
Practice Address - Phone:618-594-3671
Practice Address - Fax:618-594-8058
Is Sole Proprietor?:No
Enumeration Date:2012-09-28
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004470363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085004470OtherILLINOIS STATE LICENSE NUMBER