Healthcare Provider Details

I. General information

NPI: 1790697993
Provider Name (Legal Business Name): IXANDER CORREA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2026
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 VIA CASITAS
GREENBRAE CA
94904-1901
US

IV. Provider business mailing address

2571 39TH AVE
SAN FRANCISCO CA
94116-2752
US

V. Phone/Fax

Practice location:
  • Phone: 415-461-2300
  • Fax:
Mailing address:
  • Phone: 909-441-9991
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number309936
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: