Provider Demographics
NPI:1750871935
Name:COLLOM, NEIL EDWARD (PA-C)
Entity type:Individual
Prefix:
First Name:NEIL
Middle Name:EDWARD
Last Name:COLLOM
Suffix:
Gender:M
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 1:226 W JEAN ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33604-6644
Mailing Address - Country:US
Mailing Address - Phone:813-892-3656
Mailing Address - Fax:
Practice Address - Street 1:2502 W SAINT ISABEL ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6370
Practice Address - Country:US
Practice Address - Phone:813-874-5707
Practice Address - Fax:813-874-5908
Is Sole Proprietor?:No
Enumeration Date:2018-05-14
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9111249363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant