Provider Demographics
NPI:1518109909
Name:COLSON, JIMMY GLEN (CO)
Entity Type:Individual
Prefix:MR
First Name:JIMMY
Middle Name:GLEN
Last Name:COLSON
Suffix:
Gender:M
Credentials:CO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 S RANCHO DR
Mailing Address - Street 2:#8B
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-4844
Mailing Address - Country:US
Mailing Address - Phone:702-293-5502
Mailing Address - Fax:702-242-5572
Practice Address - Street 1:500 S RANCHO DR
Practice Address - Street 2:#8B
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4844
Practice Address - Country:US
Practice Address - Phone:702-293-5502
Practice Address - Fax:702-242-5572
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-31
Last Update Date:2009-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVH13-00347-2-143805332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100509314Medicaid
NV100509314Medicaid