Healthcare Provider Details

I. General information

NPI: 1265295331
Provider Name (Legal Business Name): BRIAN MARK COLBURN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2024
Last Update Date: 02/02/2024
Certification Date: 02/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD
GAINESVILLE FL
32610-7007
US

IV. Provider business mailing address

PO BOX 100108
GAINESVILLE FL
32610-0108
US

V. Phone/Fax

Practice location:
  • Phone: 352-265-0535
  • Fax: 352-627-4173
Mailing address:
  • Phone: 352-265-0535
  • Fax: 352-627-4173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9118189
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: