Provider Demographics
NPI:1073940557
Name:IDIEGBE, COLLINS O (ACNP)
Entity Type:Individual
Prefix:
First Name:COLLINS
Middle Name:O
Last Name:IDIEGBE
Suffix:
Gender:M
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4411 MEDICAL DR
Mailing Address - Street 2:300
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3822
Mailing Address - Country:US
Mailing Address - Phone:210-614-5400
Mailing Address - Fax:210-614-5732
Practice Address - Street 1:4411 MEDICAL DR
Practice Address - Street 2:300
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3822
Practice Address - Country:US
Practice Address - Phone:210-614-5400
Practice Address - Fax:210-614-5732
Is Sole Proprietor?:No
Enumeration Date:2013-09-30
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX751397363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care