Provider Demographics
NPI:1144306689
Name:TETZLAFF, COLLEEN HOGAN (PA-C)
Entity type:Individual
Prefix:MRS
First Name:COLLEEN
Middle Name:HOGAN
Last Name:TETZLAFF
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:COLLEEN
Other - Middle Name:
Other - Last Name:HOGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:333 COTTMAN AVE
Mailing Address - Street 2:ENROLLMENT DEPT.
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19111-2434
Mailing Address - Country:US
Mailing Address - Phone:215-214-1405
Mailing Address - Fax:
Practice Address - Street 1:333 COTTMAN AVE
Practice Address - Street 2:FOX CHASE CANCER CENTER
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19111-2434
Practice Address - Country:US
Practice Address - Phone:215-728-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04371363A00000X
PAMA053367363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
8D2670Medicare ID - Type Unspecified
Q36467Medicare UPIN