Provider Demographics
NPI:1477106391
Name:COTTER, COLLEEN L (PA-C)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:L
Last Name:COTTER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8332 LAKESHORE TRAIL EAST DR APT 926
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-4645
Mailing Address - Country:US
Mailing Address - Phone:360-635-1911
Mailing Address - Fax:
Practice Address - Street 1:530 NE GLEN OAK AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61637-0001
Practice Address - Country:US
Practice Address - Phone:309-655-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-19
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty