Provider Demographics
NPI:1447366414
Name:COLBY, MARK E (PA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:E
Last Name:COLBY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3702 NEW VISION DR BLDG B
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1703
Mailing Address - Country:US
Mailing Address - Phone:260-266-8207
Mailing Address - Fax:
Practice Address - Street 1:1314 E 7TH ST STE 103
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:IN
Practice Address - Zip Code:46706-2533
Practice Address - Country:US
Practice Address - Phone:260-927-1982
Practice Address - Fax:260-927-8380
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN10000170A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN260100DMedicare PIN
IN667640TMedicare PIN
INP00374410Medicare PIN
INS70534Medicare UPIN