MEDICARE: MR. HENRY LEE COLLINS CSA

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	363AS0400X	Surgical Physician Assistant	02164	TX

General Provider Information

NPI Number	:	1548481781
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. HENRY LEE COLLINS CSA

Provider Business Mailing Address
First Line	:	PO BOX 1733
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76101-1733
Country	:	US
Telephone Number	:	817-455-1680
Fax Number	:	817-346-9151

Provider Business Practice Location Address
First Line	:	2713 CLOVERMEADOW DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76123-2107
Country	:	US
Telephone Number	:	817-346-9151
Fax Number	:	817-346-9151

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

Provider Enumeration Date	:	05/02/2007
Last Update Date	:	07/08/2007

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