Provider Demographics
NPI:1396810529
Name:COBURN, GORDON (APRN, BC)
Entity type:Individual
Prefix:MR
First Name:GORDON
Middle Name:
Last Name:COBURN
Suffix:
Gender:M
Credentials:APRN, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 BOONE RIDGE DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-4998
Mailing Address - Country:US
Mailing Address - Phone:423-282-1480
Mailing Address - Fax:423-928-1353
Practice Address - Street 1:119 BOONE RIDGE DR
Practice Address - Street 2:SUITE 201
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37615-4998
Practice Address - Country:US
Practice Address - Phone:423-282-1480
Practice Address - Fax:423-928-1353
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2015-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11054363LA2200X, 363LP0808X
VA0024166489363LA2200X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1504748Medicaid
TNQ008267Medicaid
TNQ008267Medicaid
Q44474Medicare UPIN
VAVV9628BMedicare PIN