Provider Demographics
NPI:1730166802
Name:COLLUM, AMBER L (PAC)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:L
Last Name:COLLUM
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1803 C AVE
Mailing Address - Street 2:
Mailing Address - City:VINTON
Mailing Address - State:IA
Mailing Address - Zip Code:52349-1691
Mailing Address - Country:US
Mailing Address - Phone:515-471-9372
Mailing Address - Fax:515-471-9319
Practice Address - Street 1:1803 C AVE
Practice Address - Street 2:
Practice Address - City:VINTON
Practice Address - State:IA
Practice Address - Zip Code:52349-1691
Practice Address - Country:US
Practice Address - Phone:319-472-2304
Practice Address - Fax:319-472-4579
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001495363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAPO00055841OtherRR MEDICARE
IAI10172Medicare ID - Type Unspecified
IAPO00055841OtherRR MEDICARE