Basic Information
| Provider Information | |||||||||
| NPI: | 1912054628 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COLLIGAN | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | ANNE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2411 FOUNTAIN VIEW DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770574832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7136204000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2411 FOUNTAIN VIEW DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770574817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7134584185 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2007 | ||||||||
| LastUpdateDate: | 08/31/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 48234 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 2117297 | 05 | LA | MEDICAID | 81171H | 01 | TX-BLUE SHIELD | OTHER | 430039901 | 01 | RAILROAD MEDICARE | OTHER | 002473901 | 05 | TX | MEDICAID |