Provider Demographics
NPI:1295706505
Name:GUSSE, COLLINE N (PA)
Entity type:Individual
Prefix:
First Name:COLLINE
Middle Name:N
Last Name:GUSSE
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 247
Mailing Address - Street 2:KSB MEDICAL GROUP
Mailing Address - City:ASHTON
Mailing Address - State:IL
Mailing Address - Zip Code:61006-0247
Mailing Address - Country:US
Mailing Address - Phone:815-453-1212
Mailing Address - Fax:815-453-2823
Practice Address - Street 1:1107 S DIVISION AVE
Practice Address - Street 2:KSB MEDICAL GROUP
Practice Address - City:ASHTON
Practice Address - State:IL
Practice Address - Zip Code:61006-0247
Practice Address - Country:US
Practice Address - Phone:815-453-1212
Practice Address - Fax:815-453-2823
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL648320Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
P27656Medicare UPIN