Provider Demographics
NPI:1083956650
Name:COLON, ZARA (PA)
Entity Type:Individual
Prefix:
First Name:ZARA
Middle Name:
Last Name:COLON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 INDEPENDENCE PT
Mailing Address - Street 2:SUITE 212
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4545
Mailing Address - Country:US
Mailing Address - Phone:864-797-6306
Mailing Address - Fax:
Practice Address - Street 1:10110 CLEMSON BLVD
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29678-0812
Practice Address - Country:US
Practice Address - Phone:864-482-3148
Practice Address - Fax:864-482-0505
Is Sole Proprietor?:No
Enumeration Date:2013-03-21
Last Update Date:2016-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1908363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4697Medicaid
SCGP4697Medicaid