Provider Demographics
NPI:1104582931
Name:COLON, RAISA MARY (NP)
Entity type:Individual
Prefix:
First Name:RAISA
Middle Name:MARY
Last Name:COLON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2467 GOLDEN CAMP RD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30906-5515
Mailing Address - Country:US
Mailing Address - Phone:706-790-4440
Mailing Address - Fax:
Practice Address - Street 1:2467 GOLDEN CAMP RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30906-5515
Practice Address - Country:US
Practice Address - Phone:706-790-4440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-16
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GANP000359363LP2300X
GAGAA-NP000359363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care