Provider Demographics
NPI:1871545046
Name:MCCOLLAUM, MARC EDWIN (PA-C)
Entity type:Individual
Prefix:
First Name:MARC
Middle Name:EDWIN
Last Name:MCCOLLAUM
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
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Mailing Address - Street 1:11725 COLLIER BLVD H
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34116-6524
Mailing Address - Country:US
Mailing Address - Phone:239-349-2500
Mailing Address - Fax:239-349-2501
Practice Address - Street 1:11725 COLLIER BLVD H
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34116-6524
Practice Address - Country:US
Practice Address - Phone:239-349-2500
Practice Address - Fax:239-349-2501
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2016-12-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FL9102277363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY08XGOtherBCBS
Q28860Medicare UPIN
FLU3802WMedicare PIN