Healthcare Provider Details

I. General information

NPI: 1275969677
Provider Name (Legal Business Name): CHARLES ROBERT COLLIER III PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2013
Last Update Date: 09/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

269 PORTLAND WAY S
GALION OH
44833-2312
US

IV. Provider business mailing address

332 CONGRESS PARK DR
DAYTON OH
45459-4133
US

V. Phone/Fax

Practice location:
  • Phone: 419-468-0733
  • Fax:
Mailing address:
  • Phone: 800-726-3627
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number003838
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: