Healthcare Provider Details

I. General information

NPI: 1588829048
Provider Name (Legal Business Name): DARRELL BERNARD COLLIERS CFA PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2008
Last Update Date: 07/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15200 COMMUNITY RD
GULFPORT MS
39523
US

IV. Provider business mailing address

230 AUDUBON DRIVE
MANDEVILLE LA
70471
US

V. Phone/Fax

Practice location:
  • Phone: 228-575-7000
  • Fax:
Mailing address:
  • Phone: 985-845-1501
  • Fax: 985-845-1601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number616147
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: