Provider Demographics
NPI:1447318720
Name:COLLIN, JONATHAN (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:COLLIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 TYLER ST
Mailing Address - Street 2:
Mailing Address - City:PORT TOWNSEND
Mailing Address - State:WA
Mailing Address - Zip Code:98368-6541
Mailing Address - Country:US
Mailing Address - Phone:360-385-4555
Mailing Address - Fax:360-385-0699
Practice Address - Street 1:911 TYLER ST
Practice Address - Street 2:
Practice Address - City:PORT TOWNSEND
Practice Address - State:WA
Practice Address - Zip Code:98368-6541
Practice Address - Country:US
Practice Address - Phone:360-385-4555
Practice Address - Fax:360-385-0699
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00016094208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAA04297Medicare UPIN