Provider Demographics
NPI:1538276928
Name:COYNE, ANGELA ANN (PA)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:ANN
Last Name:COYNE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 E RIVERSIDE DRIVE
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-6237
Mailing Address - Country:US
Mailing Address - Phone:208-939-6227
Mailing Address - Fax:208-939-6442
Practice Address - Street 1:1605 E RIVERSIDE DRIVE
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6237
Practice Address - Country:US
Practice Address - Phone:208-939-6227
Practice Address - Fax:208-939-6442
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-512363AS0400X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPA-512OtherLICENSE