Provider Demographics
NPI:1669102893
Name:MCCOLLOM, CATHRYN RACHEL (PA-C)
Entity type:Individual
Prefix:MISS
First Name:CATHRYN
Middle Name:RACHEL
Last Name:MCCOLLOM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11301 CARMEL COMMONS BLVD STE 302
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-5305
Mailing Address - Country:US
Mailing Address - Phone:704-372-7974
Mailing Address - Fax:704-970-4746
Practice Address - Street 1:1315 EAST BLVD UNIT 811
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-6081
Practice Address - Country:US
Practice Address - Phone:704-221-4535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-11
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC0010-12926363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program