Provider Demographics
NPI:1134644180
Name:COLLINS, MARK WAYNE (CRNP)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:WAYNE
Last Name:COLLINS
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 S LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17042-7529
Mailing Address - Country:US
Mailing Address - Phone:717-273-6741
Mailing Address - Fax:
Practice Address - Street 1:615 CUMBERLAND ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-5233
Practice Address - Country:US
Practice Address - Phone:717-273-6741
Practice Address - Fax:717-273-6337
Is Sole Proprietor?:No
Enumeration Date:2017-08-11
Last Update Date:2017-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP017583363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily