| Doctor Name: | JOHNNY KEITH COLEMAN |
| NPI Number: | 1174558845 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | P.A.-C. |
| License Number: | PA13661 |
| Business Practice Address: | 3302 Renner Dr Fortuna, CA - 955407103 |
| Business Phone Number: | 7077253318 |
| Business Fax Number: | 7077259396 |
| Mailing Address: | 3302 Renner Dr, FORTUNA |
| State: | CA |
| Postal Code: | 955403120 |
| Phone Number: | 7077253318 |
| Fax Number: | 7077259396 |
| NPI Enumeration Date: | 07/11/2006 |
| NPI Last Update Date: | 06/30/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363LP2300X |
| License Number: | PA13661 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | CA |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Nurse Practitioner |
| Taxonomy Specialization: | Primary Care |
| Taxonomy Definition: | |