Provider Demographics
NPI:1548722242
Name:COLLINS, ADDISON MAE (PA)
Entity type:Individual
Prefix:
First Name:ADDISON
Middle Name:MAE
Last Name:COLLINS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1905 W COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-4061
Mailing Address - Country:US
Mailing Address - Phone:406-587-4432
Mailing Address - Fax:406-587-7015
Practice Address - Street 1:1905 W COLLEGE ST
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-4061
Practice Address - Country:US
Practice Address - Phone:406-587-4432
Practice Address - Fax:406-587-7015
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-02
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT70843363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical