Provider Demographics
NPI:1144021072
Name:COLLAZOS MORAN, BRENDA YVETTE
Entity type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:YVETTE
Last Name:COLLAZOS MORAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3530 81ST ST APT 1R
Mailing Address - Street 2:
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-5032
Mailing Address - Country:US
Mailing Address - Phone:347-813-8037
Mailing Address - Fax:
Practice Address - Street 1:7206 NORTHERN BLVD FL 2
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-1049
Practice Address - Country:US
Practice Address - Phone:866-670-6824
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-24
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033600363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant