Provider Demographics
NPI:1740762384
Name:VALDEZ, COLLEEN ROSE (PA-C)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:ROSE
Last Name:VALDEZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:ROSE
Other - Last Name:VALDEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:2749 KATE BOND RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38133-8140
Mailing Address - Country:US
Mailing Address - Phone:901-871-9470
Mailing Address - Fax:
Practice Address - Street 1:1774 MCFARLAND BLVD N
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35406-2136
Practice Address - Country:US
Practice Address - Phone:205-759-2520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-30
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA0000003535363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical