Provider Demographics
NPI:1467931360
Name:COLLEVECCHIO, DIRK M (RN, AGNP-C)
Entity Type:Individual
Prefix:
First Name:DIRK
Middle Name:M
Last Name:COLLEVECCHIO
Suffix:
Gender:M
Credentials:RN, AGNP-C
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Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:349 27TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94121-1811
Mailing Address - Country:US
Mailing Address - Phone:443-243-3136
Mailing Address - Fax:
Practice Address - Street 1:4150 CLEMENT ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94121-1563
Practice Address - Country:US
Practice Address - Phone:415-221-4810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-10
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95015285363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health