Provider Demographics
NPI:1710053533
Name:KOLLMAN, KELLY M (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:KOLLMAN
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:P.O. BOX 29901
Mailing Address - Street 2:DEPT. 994
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85038-0901
Mailing Address - Country:US
Mailing Address - Phone:480-219-6662
Mailing Address - Fax:480-219-6662
Practice Address - Street 1:8761 E BELL RD
Practice Address - Street 2:SUITE 105
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-1315
Practice Address - Country:US
Practice Address - Phone:480-219-6662
Practice Address - Fax:480-219-6596
Is Sole Proprietor?:No
Enumeration Date:2006-11-24
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ3449363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP00624725OtherRAILROAD MEDICARE
AZ160229Medicaid
AZ160229Medicaid
AZZ112095Medicare PIN