Provider Demographics
NPI:1508960915
Name:COLLARD, TAMARA (PA)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:COLLARD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:TAMARA
Other - Middle Name:
Other - Last Name:EDWARDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 155
Mailing Address - Street 2:
Mailing Address - City:CHRISTOPHER
Mailing Address - State:IL
Mailing Address - Zip Code:62822-0155
Mailing Address - Country:US
Mailing Address - Phone:618-724-2401
Mailing Address - Fax:618-724-4628
Practice Address - Street 1:1564 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:DU QUOIN
Practice Address - State:IL
Practice Address - Zip Code:62832-3849
Practice Address - Country:US
Practice Address - Phone:618-542-8702
Practice Address - Fax:618-542-8792
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-001366363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP06705Medicare UPIN