Provider Demographics
NPI:1467420117
Name:MCCOLLOUGH, PAULA L (CNS)
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:L
Last Name:MCCOLLOUGH
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4510 WEST DR
Mailing Address - Street 2:
Mailing Address - City:BELTON
Mailing Address - State:TX
Mailing Address - Zip Code:76513-4762
Mailing Address - Country:US
Mailing Address - Phone:254-231-9636
Mailing Address - Fax:254-939-7711
Practice Address - Street 1:4100 DUVAL RD
Practice Address - Street 2:BLDG 3 SUITE 200
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-3550
Practice Address - Country:US
Practice Address - Phone:512-485-7200
Practice Address - Fax:512-485-7220
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-09
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX541187364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX088301901Medicaid
TX088301901Medicaid
TX85N133Medicare ID - Type UnspecifiedMEDICARE