Provider Demographics
NPI:1982643292
Name:COLSTON, ADRIENNE WINIFRED (PA)
Entity Type:Individual
Prefix:
First Name:ADRIENNE
Middle Name:WINIFRED
Last Name:COLSTON
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 1:14100 NACOGDOCHES RD STE 116
Mailing Address - Street 2:WELLMED AT NORTHERN HILLS
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78247-1903
Mailing Address - Country:US
Mailing Address - Phone:210-653-8989
Mailing Address - Fax:210-590-4608
Practice Address - Street 1:14100 NACOGDOCHES RD STE 116
Practice Address - Street 2:WELLMED AT NORTHERN HILLS
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78247-1903
Practice Address - Country:US
Practice Address - Phone:210-653-8989
Practice Address - Fax:210-590-4608
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-05
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04612363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX196393602Medicaid
TX196393603Medicaid
TX8L19823Medicare PIN
TXTXB134089Medicare PIN