Provider Demographics
NPI:1366118671
Name:IYAMAH, COLLINS (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:COLLINS
Middle Name:
Last Name:IYAMAH
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 N WILMOT RD STE A200
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-4416
Mailing Address - Country:US
Mailing Address - Phone:520-403-4749
Mailing Address - Fax:888-851-7021
Practice Address - Street 1:1500 N WILMOT RD STE A200
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-4416
Practice Address - Country:US
Practice Address - Phone:817-420-2968
Practice Address - Fax:682-282-3115
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-17
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2021028178363LP0808X
TX1053243363LP0808X
NY403918363LP0808X
WA61390990363LP0808X
AZ270410363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty