Healthcare Provider Details

I. General information

NPI: 1467035428
Provider Name (Legal Business Name): COLSTON YEAN RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2021
Last Update Date: 04/28/2021
Certification Date: 04/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 HUNTER LN
CAMP HILL PA
17011-2499
US

IV. Provider business mailing address

436 SEVILLE ST
PHILADELPHIA PA
19128-3630
US

V. Phone/Fax

Practice location:
  • Phone: 800-748-3243
  • Fax:
Mailing address:
  • Phone: 215-490-8571
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN710068
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: