Basic Information
| Provider Information | |||||||||
| NPI: | 1295891547 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COLLINS | ||||||||
| FirstName: | EDSMOND | ||||||||
| MiddleName: | JERRY | ||||||||
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| Credential: | PA PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3900 DORAL DR | ||||||||
| Address2: | |||||||||
| City: | FAIRFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074252824 | ||||||||
| FaxNumber: | 7074258970 | ||||||||
| Practice Location | |||||||||
| Address1: | 3 SOUTH LINDEN AVE | ||||||||
| Address2: | |||||||||
| City: | SSF | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6505892647 | ||||||||
| FaxNumber: | 6505835549 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA10067 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.