Provider Demographics
NPI:1336259993
Name:PICCIOCCA, COLBY LYNN (PA)
Entity Type:Individual
Prefix:MRS
First Name:COLBY
Middle Name:LYNN
Last Name:PICCIOCCA
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 1:4016 HUNTSCROFT LN
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-4777
Mailing Address - Country:US
Mailing Address - Phone:336-923-2188
Mailing Address - Fax:
Practice Address - Street 1:4016 HUNTSCROFT LN
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-4777
Practice Address - Country:US
Practice Address - Phone:336-923-2188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY8407-1363AS0400X
NC0010-01109363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical