MEDICARE: KIMEN M COLGAN PA

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	1366	WI
2	363A00000X	Physician Assistant	3531	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1699739227
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMEN M COLGAN PA

Provider Business Mailing Address
First Line	:	575 PRICE ST
Second Line	:	STE 101
City	:	PISMO BEACH
State	:	CA
Zip	:	93449-2553
Country	:	US
Telephone Number	:	805-481-3685
Fax Number	:	805-481-5245

Provider Business Practice Location Address
First Line	:	575 PRICE ST
Second Line	:	SUITE101
City	:	PISMO BEACH
State	:	CA
Zip	:	93449-2553
Country	:	US
Telephone Number	:	805-481-3685
Fax Number	:	805-481-5245

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

Provider Enumeration Date	:	04/12/2006
Last Update Date	:	09/19/2016

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Directions to “ KIMEN M COLGAN PA” Practice Location

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