Provider Demographics
NPI: | 1851326045 |
---|---|
Name: | MCCOLLY, JAMES D (MPAS, PA-C) |
Entity Type: | Individual |
Prefix: | MR |
First Name: | JAMES |
Middle Name: | D |
Last Name: | MCCOLLY |
Suffix: | |
Gender: | M |
Credentials: | MPAS, 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: | 444 W FORT ST. |
Mailing Address - Street 2: | CRH 2ND FLOOR |
Mailing Address - City: | BOISE |
Mailing Address - State: | ID |
Mailing Address - Zip Code: | 83702-4535 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 208-422-1018 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 444 W FORT ST. |
Practice Address - Street 2: | CRH 2ND FLOOR |
Practice Address - City: | BOISE |
Practice Address - State: | ID |
Practice Address - Zip Code: | 83702-4535 |
Practice Address - Country: | US |
Practice Address - Phone: | 208-422-1018 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-07-12 |
Last Update Date: | 2023-09-28 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
ID | PA570 | 363A00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
ID | 807282900 | Medicaid | |
OR | R140656 | Medicare PIN | |
Q54559 | Medicare UPIN | ||
ID | 16671503 | Medicare PIN | |
ID | 16671501 | Medicare PIN | |
OR | R140657 | Medicare PIN | |
ID | 807282900 | Medicaid |