Healthcare Provider Details

I. General information

NPI: 1003732454
Provider Name (Legal Business Name): JAMES COLLAZO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2026
Last Update Date: 06/29/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

LOCAL 1, CARR PR-1 KM 11.29
JUANA DIAZ PR
00795
US

IV. Provider business mailing address

CARR 1 KM 11.29 LOCAL 1
JUANA DIAZ PR
00795
US

V. Phone/Fax

Practice location:
  • Phone: 787-432-6439
  • Fax:
Mailing address:
  • Phone: 787-432-6439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3163
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: