Provider Demographics
NPI:1528332939
Name:COLLIVER, JOSHUA SCOTT (PA-C)
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:SCOTT
Last Name:COLLIVER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1296 SIMS ST STE B
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-3873
Mailing Address - Country:US
Mailing Address - Phone:770-534-1856
Mailing Address - Fax:
Practice Address - Street 1:1296 SIMS ST STE B
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3873
Practice Address - Country:US
Practice Address - Phone:770-534-1856
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-02
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
IN10001751A363A00000X
GA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN264430255Medicare PIN
INP01453394Medicare PIN