Provider Demographics
NPI:1588829048
Name:COLLIERS, DARRELL BERNARD (CFA PA)
Entity Type:Individual
Prefix:MR
First Name:DARRELL
Middle Name:BERNARD
Last Name:COLLIERS
Suffix:
Gender:M
Credentials:CFA PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 AUDUBON DRIVE
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70471
Mailing Address - Country:US
Mailing Address - Phone:985-845-1501
Mailing Address - Fax:985-845-1601
Practice Address - Street 1:15200 COMMUNITY RD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39523
Practice Address - Country:US
Practice Address - Phone:228-575-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-24
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS616147363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
616147OtherNATL 1ST ASSIST CORP