Basic Information
| Provider Information | |||||||||
| NPI: | 1184987877 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GAGE | ||||||||
| FirstName: | COLIN | ||||||||
| MiddleName: | HAYES | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 10900 WORLD TRADE BLVD | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276174202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6307400574 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2880 TRICOM ST | ||||||||
| Address2: | |||||||||
| City: | NORTH CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294069171 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437975050 | ||||||||
| FaxNumber: | 8437973633 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2012 | ||||||||
| LastUpdateDate: | 08/06/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | TL 1789 | SC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | TL 1789 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | PA0971 | 01 | SC | GROUP MEDICAID # | OTHER | 042299001 | 01 | SC | GROUP DMERC # | OTHER | 1225006760 | 01 | SC | GROUP NPI # | OTHER | 1701 | 01 | SC | GROUP MEDICARE PIN # | OTHER | 20076508 | 01 | SC | GROUP SELECT HEALTH DME # | OTHER | 20000499 | 01 | SC | GROUP SELECT HEALTH PROVIDER # | OTHER | 461555 | 01 | SC | GROUP MEDICARE DME # | OTHER | 57-0634057 | 01 | SC | GROUP TAX ID # | OTHER | 1326287434 | 01 | SC | GROUP MEDICARE DME NPI # | OTHER | CD28777 | 01 | SC | GROUP MEDICARE RAILROAD # | OTHER |