Provider Demographics
NPI: | 1033325915 |
---|---|
Name: | COLLA, PETER J (PT) |
Entity Type: | Individual |
Prefix: | |
First Name: | PETER |
Middle Name: | J |
Last Name: | COLLA |
Suffix: | |
Gender: | M |
Credentials: | PT |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 3445 W VALLEY VIEW TRL |
Mailing Address - Street 2: | |
Mailing Address - City: | PHOENIX |
Mailing Address - State: | AZ |
Mailing Address - Zip Code: | 85086-9155 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 602-315-6894 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 3445 W VALLEY VIEW TRL |
Practice Address - Street 2: | |
Practice Address - City: | PHOENIX |
Practice Address - State: | AZ |
Practice Address - Zip Code: | 85086-9155 |
Practice Address - Country: | US |
Practice Address - Phone: | 602-315-6894 |
Practice Address - Fax: | |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2007-05-15 |
Last Update Date: | 2012-12-04 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
AZ | 1712 | 225100000X, 2251X0800X, 2251S0007X, 2251E1300X, 2251G0304X, 2251C2600X, 2251P0200X, 2251N0400X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2251X0800X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
No | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | |
No | 2251S0007X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Sports |
No | 2251E1300X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Electrophysiology, Clinical |
No | 2251G0304X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Geriatrics |
No | 2251C2600X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Cardiopulmonary |
No | 2251P0200X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Pediatrics |
No | 2251N0400X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Neurology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
AZ | 782880 | Medicaid | |
AZ | RPT1712 | Medicare ID - Type Unspecified | |
AZ | 782880 | Medicaid |