Healthcare Provider Details

I. General information

NPI: 1457708679
Provider Name (Legal Business Name): CAITLYN MARIE COLUCCI PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2016
Last Update Date: 09/15/2021
Certification Date: 09/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 S 54TH ST
PHILADELPHIA PA
19143-1900
US

IV. Provider business mailing address

501 S 54TH ST
PHILADELPHIA PA
19143-1900
US

V. Phone/Fax

Practice location:
  • Phone: 215-748-9707
  • Fax: 215-748-9708
Mailing address:
  • Phone: 215-748-9707
  • Fax: 215-748-9708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA062533
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: