Provider Demographics
NPI:1336713148
Name:COLLINS, ETHAN (FNP)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:COLLINS
Suffix:
Gender:M
Credentials:FNP
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 90
Mailing Address - Street 2:
Mailing Address - City:COEBURN
Mailing Address - State:VA
Mailing Address - Zip Code:24230-0090
Mailing Address - Country:US
Mailing Address - Phone:276-455-5556
Mailing Address - Fax:
Practice Address - Street 1:208W FRONT STREET
Practice Address - Street 2:
Practice Address - City:COEBURN
Practice Address - State:VA
Practice Address - Zip Code:24230
Practice Address - Country:US
Practice Address - Phone:276-455-5556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-17
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001238326163WG0000X
VA0024183385363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice