MEDICARE: KEEGAN CORBETT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	744385-01	NY
2	367500000X	Certified Registered Nurse Anesthetist	151335	NY

General Provider Information

NPI Number	:	1659111334
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEEGAN CORBETT

Provider Business Mailing Address
First Line	:	108 COMMODORE CIR
Second Line	:
City	:	PORT JEFFERSON STATION
State	:	NY
Zip	:	11776-2266
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	108 COMMODORE CIR
Second Line	:
City	:	PORT JEFFERSON STATION
State	:	NY
Zip	:	11776-2266
Country	:	US
Telephone Number	:	802-681-8317
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/29/2024
Last Update Date	:	10/31/2024

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Directions to “ KEEGAN CORBETT ” Practice Location

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