Provider Demographics
NPI:1295891547
Name:COLLINS, EDSMOND JERRY (PA PHD)
Entity type:Individual
Prefix:
First Name:EDSMOND
Middle Name:JERRY
Last Name:COLLINS
Suffix:
Gender:M
Credentials:PA PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3900 DORAL DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533
Mailing Address - Country:US
Mailing Address - Phone:707-425-2824
Mailing Address - Fax:707-425-8970
Practice Address - Street 1:3 SOUTH LINDEN AVE
Practice Address - Street 2:
Practice Address - City:SSF
Practice Address - State:CA
Practice Address - Zip Code:94080
Practice Address - Country:US
Practice Address - Phone:650-589-2647
Practice Address - Fax:650-583-5549
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA10067363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant