Provider Demographics
NPI:1154314730
Name:COLLISON, WILLIAM WADE (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:WADE
Last Name:COLLISON
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:PO BOX 10880
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86304-0880
Mailing Address - Country:US
Mailing Address - Phone:928-759-5987
Mailing Address - Fax:928-458-2039
Practice Address - Street 1:1050 GAIL GARDNER WAY
Practice Address - Street 2:200
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-1630
Practice Address - Country:US
Practice Address - Phone:928-778-3838
Practice Address - Fax:928-778-5630
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-29
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ106442086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ21-13-A644OtherWORKER'S COMPENSATION
AZ24000709OtherRAILROAD MEDICARE
AZ238354Medicaid
AZZ122948Medicare PIN
AZ238354Medicaid