Provider Demographics
NPI:1437918471
Name:CLIFFORD, COLLEEN (PA-C)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:CLIFFORD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:
Other - Last Name:COORS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9505 MONTGOMERY RD STE 202
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:OH
Mailing Address - Zip Code:45242-7248
Mailing Address - Country:US
Mailing Address - Phone:513-407-6946
Mailing Address - Fax:513-715-0514
Practice Address - Street 1:9505 MONTGOMERY RD STE 202
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:OH
Practice Address - Zip Code:45242-7248
Practice Address - Country:US
Practice Address - Phone:513-407-6946
Practice Address - Fax:513-715-0514
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-13
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
OH363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant