Provider Demographics
NPI:1982841573
Name:COLEMAN, JOSHUA L (CRNA)
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:L
Last Name:COLEMAN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 COTTONWOOD CT # D150
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-6576
Mailing Address - Country:US
Mailing Address - Phone:208-917-2713
Mailing Address - Fax:208-955-2029
Practice Address - Street 1:100 COTTONWOOD CT # D150
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6576
Practice Address - Country:US
Practice Address - Phone:208-917-2713
Practice Address - Fax:208-955-2029
Is Sole Proprietor?:No
Enumeration Date:2009-01-19
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID81381208VP0014X
IDRNA741367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1982841573Medicaid