Provider Demographics
NPI:1902581093
Name:BROWN, COLLEEN KELLEY (PA-C)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:KELLEY
Last Name:BROWN
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 1:1820 CENTENNIAL WAY
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92026-3616
Mailing Address - Country:US
Mailing Address - Phone:916-384-8141
Mailing Address - Fax:
Practice Address - Street 1:6386 ALVARADO CT STE 101
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-4906
Practice Address - Country:US
Practice Address - Phone:858-900-9490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-16
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA62866363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant