Provider Demographics
NPI:1801827233
Name:NAKAMURA, COLLEEN (PA)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:NAKAMURA
Suffix:
Gender:F
Credentials:PA
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 2489
Mailing Address - Street 2:#1
Mailing Address - City:FOREST
Mailing Address - State:VA
Mailing Address - Zip Code:24551-6489
Mailing Address - Country:US
Mailing Address - Phone:434-382-1139
Mailing Address - Fax:434-525-5748
Practice Address - Street 1:2137 LAKESIDE DR
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-6806
Practice Address - Country:US
Practice Address - Phone:434-385-4184
Practice Address - Fax:434-385-8616
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001810363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
C03658OtherMEDICARE GROUP PTAN
1528155892OtherCVFP CORPORATE NPI
1972680049OtherCVFP SITE NPI
1528155892OtherCVFP CORPORATE NPI
1972680049OtherCVFP SITE NPI