Provider Demographics
NPI:1689900375
Name:PENN, COLIN (PA-C)
Entity Type:Individual
Prefix:
First Name:COLIN
Middle Name:
Last Name:PENN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 W CRYSTAL LAKE ST
Mailing Address - Street 2:STE 200
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-4475
Mailing Address - Country:US
Mailing Address - Phone:407-254-2500
Mailing Address - Fax:407-423-2789
Practice Address - Street 1:25 W CRYSTAL LAKE ST
Practice Address - Street 2:STE 200
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-4475
Practice Address - Country:US
Practice Address - Phone:407-254-2500
Practice Address - Fax:407-423-2789
Is Sole Proprietor?:No
Enumeration Date:2009-10-30
Last Update Date:2015-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9105099363AS0400X
FL9015099363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001514400Medicaid
FLCS284XMedicare PIN
FLCS284YMedicare PIN