MEDICARE: MR. COREY LEE CAMPBELL PA-C

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	363A00000X	Physician Assistant	TC162	KY

General Provider Information

NPI Number	:	1851060172
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. COREY LEE CAMPBELL PA-C

Provider Business Mailing Address
First Line	:	526 ROUND RIDGE RD
Second Line	:
City	:	PINEVILLE
State	:	KY
Zip	:	40977-7008
Country	:	US
Telephone Number	:	859-409-6154
Fax Number	:

Provider Business Practice Location Address
First Line	:	526 ROUND RIDGE RD
Second Line	:
City	:	PINEVILLE
State	:	KY
Zip	:	40977-7008
Country	:	US
Telephone Number	:	859-409-6154
Fax Number	:

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

Provider Enumeration Date	:	09/09/2021
Last Update Date	:	01/20/2022

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