Provider Demographics
NPI:1124077151
Name:COLLINS, BRANDIE DAWN (PA)
Entity type:Individual
Prefix:
First Name:BRANDIE
Middle Name:DAWN
Last Name:COLLINS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:BRANDIE
Other - Middle Name:D
Other - Last Name:DEMOND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-2222
Mailing Address - Fax:
Practice Address - Street 1:520 S EAGLE RD
Practice Address - Street 2:STE 3102
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6351
Practice Address - Country:US
Practice Address - Phone:208-706-5100
Practice Address - Fax:208-706-5169
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2013-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA188363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID20000626Medicare PIN