Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 213E00000X | Podiatrist | CPO 2469 | VA |
N | 222Z00000X | Podiatrist | CPO 2469 | VA |
Y | 224P00000X | Prosthetist | CPO 2469 | VA |
NPI | 1417994500 |
---|---|
Provider Name | Mr. Richard Shane Coltrain |
First Address | Greenville, NC 27834-5052 |
Second Address | Greenville, NC 27834-5052 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/05/2006 |
Last Update Date | 03/04/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0464J | NC BCBS PROVIDER# (01) | NC |
7795272 | (05) | NC |
ABC CPO 2469 | INDIVIDUAL ABC CERTIFICATION# (01) | NC |