Provider Demographics
NPI:1780107169
Name:CUSICK, COLIN GLYNN (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:COLIN
Middle Name:GLYNN
Last Name:CUSICK
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8238 GOLF LINKS RD
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94605-3537
Mailing Address - Country:US
Mailing Address - Phone:313-268-4906
Mailing Address - Fax:
Practice Address - Street 1:3901 LONE TREE WAY
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94509-6200
Practice Address - Country:US
Practice Address - Phone:925-779-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-18
Last Update Date:2017-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54485363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant