Basic Information
| Provider Information | |||||||||
| NPI: | 1528008760 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLLETT | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 217 | ||||||||
| Address2: | |||||||||
| City: | ROCK CAVE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 262340217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3049246262 | ||||||||
| FaxNumber: | 3049246699 | ||||||||
| Practice Location | |||||||||
| Address1: | RT. 4 & 20 S INTERSECTION | ||||||||
| Address2: | |||||||||
| City: | ROCK CAVE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 26234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3049246262 | ||||||||
| FaxNumber: | 3049246969 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 04/11/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 00510 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 3810000539 | 05 | WV | MEDICAID | 001721546 | 01 | WV | MS BCBS | OTHER |