Provider Demographics
NPI:1659986743
Name:BARRY, COLLIN JEFFERY
Entity Type:Individual
Prefix:
First Name:COLLIN
Middle Name:JEFFERY
Last Name:BARRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2220 E FRANKLIN AVE APT 315
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-2284
Mailing Address - Country:US
Mailing Address - Phone:262-496-8462
Mailing Address - Fax:
Practice Address - Street 1:2220 E FRANKLIN AVE APT 315
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-2284
Practice Address - Country:US
Practice Address - Phone:262-496-8462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-15
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL085009343363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program