Provider Demographics
NPI:1669520854
Name:COLLINS, NICHOLAS (PA-C, LAC, DIPLOM)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:COLLINS
Suffix:
Gender:M
Credentials:PA-C, LAC, DIPLOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3433 BRUNELL DR
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94602-4104
Mailing Address - Country:US
Mailing Address - Phone:510-847-0879
Mailing Address - Fax:
Practice Address - Street 1:2300 HENRY AVE
Practice Address - Street 2:
Practice Address - City:PINOLE
Practice Address - State:CA
Practice Address - Zip Code:94564-1714
Practice Address - Country:US
Practice Address - Phone:510-847-0879
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-06
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10162171100000X
CAPA22910363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA22910OtherCERTIFIED PHYSICIAN ASSISTANT CALIFORNIA
CAAC10162OtherCALIFORNIA ACUPUNCTURE BOARD