Provider Demographics
NPI:1700866647
Name:COLLINS, BEVERLY ANN (PA C)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:ANN
Last Name:COLLINS
Suffix:
Gender:F
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 1:8095 SPYGLASS HILL ROAD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940
Mailing Address - Country:US
Mailing Address - Phone:321-757-0577
Mailing Address - Fax:321-757-0474
Practice Address - Street 1:8095 SPYGLASS HILL ROAD
Practice Address - Street 2:SUITE 101
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940
Practice Address - Country:US
Practice Address - Phone:321-757-0577
Practice Address - Fax:321-757-0474
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA3687363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL069221200Medicaid
FLU0944WMedicare UPIN
P92192Medicare UPIN
FLU0944YMedicare ID - Type Unspecified