Healthcare Provider Details

I. General information

NPI: 1730166802
Provider Name (Legal Business Name): AMBER L COLLUM PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2005
Last Update Date: 10/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1803 C AVE
VINTON IA
52349-1691
US

IV. Provider business mailing address

1803 C AVE
VINTON IA
52349-1691
US

V. Phone/Fax

Practice location:
  • Phone: 319-472-2304
  • Fax: 319-472-4579
Mailing address:
  • Phone: 515-471-9372
  • Fax: 515-471-9319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number001495
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: