Healthcare Provider Details

I. General information

NPI: 1487618260
Provider Name (Legal Business Name): ANGELO SAMUEL COLABIANCHI PA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 TURNER ST SUITE B
PENSACOLA FL
32508-5228
US

IV. Provider business mailing address

450 TURNER ST SUITE B
PENSACOLA FL
32508-5228
US

V. Phone/Fax

Practice location:
  • Phone: 850-452-5242
  • Fax:
Mailing address:
  • Phone: 850-452-5242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2316
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: