MEDICARE: MR. JOHN ROBERT COLLEN PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PA 17169	CA
2	363A00000X	Physician Assistant	4777	SC

General Provider Information

NPI Number	:	1215058037
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOHN ROBERT COLLEN PA-C

Provider Business Mailing Address
First Line	:	300 E MCBEE AVE FL 4
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29601-2842
Country	:	US
Telephone Number	:	864-522-8603
Fax Number	:

Provider Business Practice Location Address
First Line	:	905 VERDAE BLVD STE 101
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29607-4098
Country	:	US
Telephone Number	:	864-286-7550
Fax Number	:	864-286-7551

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/02/2007
Last Update Date	:	03/23/2023

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Directions to “ MR. JOHN ROBERT COLLEN PA-C” Practice Location

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