Provider Demographics
NPI:1619157195
Name:COLLINS, CHANNA S (PA-C)
Entity Type:Individual
Prefix:
First Name:CHANNA
Middle Name:S
Last Name:COLLINS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CHANNA
Other - Middle Name:S
Other - Last Name:BAILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:600 GRESHAM DR STE 8600
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23507-1904
Mailing Address - Country:US
Mailing Address - Phone:757-388-6005
Mailing Address - Fax:757-388-6006
Practice Address - Street 1:600 GRESHAM DR STE 8600
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1904
Practice Address - Country:US
Practice Address - Phone:757-388-6005
Practice Address - Fax:757-388-6006
Is Sole Proprietor?:No
Enumeration Date:2007-11-13
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002526363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VV5908AMedicare PIN