Provider Demographics
NPI:1134654643
Name:PROKSCH, COLLIN
Entity Type:Individual
Prefix:
First Name:COLLIN
Middle Name:
Last Name:PROKSCH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5529 BEL SHORE LN
Mailing Address - Street 2:
Mailing Address - City:SCHOOLCRAFT
Mailing Address - State:MI
Mailing Address - Zip Code:49087-8105
Mailing Address - Country:US
Mailing Address - Phone:269-532-4855
Mailing Address - Fax:
Practice Address - Street 1:5529 BEL SHORE LN
Practice Address - Street 2:
Practice Address - City:SCHOOLCRAFT
Practice Address - State:MI
Practice Address - Zip Code:49087-8105
Practice Address - Country:US
Practice Address - Phone:269-532-4855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-23
Last Update Date:2017-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302042676390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program