Provider Demographics
NPI:1548598386
Name:KOLPAK, COLLEEN NELL (PA-C)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:NELL
Last Name:KOLPAK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:NELL
Other - Last Name:KIRBY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:506 S 17TH ST
Mailing Address - Street 2:APT. B
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19146-1513
Mailing Address - Country:US
Mailing Address - Phone:425-753-3434
Mailing Address - Fax:
Practice Address - Street 1:5501 OLD YORK RD
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141-3018
Practice Address - Country:US
Practice Address - Phone:425-753-3434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-04
Last Update Date:2017-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA054155363A00000X
IL085004272363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
108878OtherNATIONAL COMMISSION ON CERTIFICATION OF PHYSICIAN ASSISTANTS