Provider Demographics
NPI:1851326045
Name:MCCOLLY, JAMES D (MPAS, PA-C)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:D
Last Name:MCCOLLY
Suffix:
Gender:M
Credentials:MPAS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:444 W FORT ST.
Mailing Address - Street 2:CRH 2ND FLOOR
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-4535
Mailing Address - Country:US
Mailing Address - Phone:208-422-1018
Mailing Address - Fax:
Practice Address - Street 1:444 W FORT ST.
Practice Address - Street 2:CRH 2ND FLOOR
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4535
Practice Address - Country:US
Practice Address - Phone:208-422-1018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA570363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807282900Medicaid
ORR140656Medicare PIN
Q54559Medicare UPIN
ID16671503Medicare PIN
ID16671501Medicare PIN
ORR140657Medicare PIN
ID807282900Medicaid