Provider Demographics
NPI:1154358885
Name:KOLLBAUM, KEVIN GENE (PA)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:GENE
Last Name:KOLLBAUM
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1614 DIAMOND STREET PL
Mailing Address - Street 2:
Mailing Address - City:ONAWA
Mailing Address - State:IA
Mailing Address - Zip Code:51040-1554
Mailing Address - Country:US
Mailing Address - Phone:712-423-1525
Mailing Address - Fax:712-423-2528
Practice Address - Street 1:1614 DIAMOND STREET PL
Practice Address - Street 2:
Practice Address - City:ONAWA
Practice Address - State:IA
Practice Address - Zip Code:51040-1554
Practice Address - Country:US
Practice Address - Phone:712-423-1525
Practice Address - Fax:712-423-2528
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001521363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAMK1023605OtherDEA
IAI20912Medicare PIN
IAMK1023605OtherDEA