Basic Information
| Provider Information | |||||||||
| NPI: | 1528315538 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COLVIN | ||||||||
| FirstName: | JED | ||||||||
| MiddleName: | THOMAS | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 103 PROVIDENCE MINE RD STE 202 | ||||||||
| Address2: | |||||||||
| City: | NEVADA CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959592949 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5304708377 | ||||||||
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| Practice Location | |||||||||
| Address1: | 155 GLASSON WAY | ||||||||
| Address2: | |||||||||
| City: | GRASS VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959455723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302746000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2012 | ||||||||
| LastUpdateDate: | 08/08/2012 | ||||||||
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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 | 363LF0000X | 22027 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.