Healthcare Provider Details

I. General information

NPI: 1134585409
Provider Name (Legal Business Name): JAMES MICHAEL COLL JR. MMS, ATC, CSCS, PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2016
Last Update Date: 09/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3410 EXECUTIVE DR #103
RALEIGH NC
27609-7450
US

IV. Provider business mailing address

3410 EXECUTIVE DR STE 103
RALEIGH NC
27609-7457
US

V. Phone/Fax

Practice location:
  • Phone: 919-872-5296
  • Fax:
Mailing address:
  • Phone: 919-872-5296
  • Fax: 919-850-9718

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-06132
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: