Provider Demographics
NPI:1740206630
Name:MARCHAND, KOLLEEN (PA-C)
Entity Type:Individual
Prefix:
First Name:KOLLEEN
Middle Name:
Last Name:MARCHAND
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:PO BOX 337
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-0337
Mailing Address - Country:US
Mailing Address - Phone:801-773-4840
Mailing Address - Fax:801-525-8151
Practice Address - Street 1:1477 N 2000 W
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:UT
Practice Address - Zip Code:84015-8638
Practice Address - Country:US
Practice Address - Phone:801-773-4840
Practice Address - Fax:801-525-8151
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5398618-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q42791Medicare UPIN
UT005700529Medicare ID - Type Unspecified