Provider Demographics
NPI:1467624023
Name:PINGSTON, COLLEEN (PA)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:PINGSTON
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 1:14460 LAKESIDE CIR
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48313-1348
Mailing Address - Country:US
Mailing Address - Phone:586-685-3285
Mailing Address - Fax:
Practice Address - Street 1:14460 LAKESIDE CIRCLE
Practice Address - Street 2:100
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48313
Practice Address - Country:US
Practice Address - Phone:586-685-3285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-24
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MICM005015363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MICM005015OtherSTATE LICENCE NUMBER