Provider Demographics
NPI:1053355594
Name:COLLINS, BEVERLY C (CRNA)
Entity type:Individual
Prefix:MS
First Name:BEVERLY
Middle Name:C
Last Name:COLLINS
Suffix:
Gender:F
Credentials:CRNA
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 677
Mailing Address - Street 2:
Mailing Address - City:LINCOLNTON
Mailing Address - State:NC
Mailing Address - Zip Code:28093-0677
Mailing Address - Country:US
Mailing Address - Phone:704-735-3071
Mailing Address - Fax:704-735-0584
Practice Address - Street 1:200 GAMBLE DR
Practice Address - Street 2:
Practice Address - City:LINCOLNTON
Practice Address - State:NC
Practice Address - Zip Code:28092-4421
Practice Address - Country:US
Practice Address - Phone:704-735-3071
Practice Address - Fax:704-735-0584
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC063226367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8000175Medicaid
260515Medicare ID - Type UnspecifiedMCR PROVIDER #