Healthcare Provider Details

I. General information

NPI: 1063244564
Provider Name (Legal Business Name): JASMINE AGABIN CORPUZ PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2024
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 S ALSTON ST
FOLEY AL
36535-1914
US

IV. Provider business mailing address

222 S ALSTON ST
FOLEY AL
36535-1914
US

V. Phone/Fax

Practice location:
  • Phone: 850-633-4877
  • Fax:
Mailing address:
  • Phone: 850-633-4877
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9121716
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: