Healthcare Provider Details

I. General information

NPI: 1154040178
Provider Name (Legal Business Name): CORINNE ERICA MAXWELL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CORINNE ERICA BLAINE

II. Dates (important events)

Enumeration Date: 08/23/2022
Last Update Date: 08/17/2024
Certification Date: 08/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 E ARROW HWY
UPLAND CA
91786-4910
US

IV. Provider business mailing address

1230 E ARROW HWY
UPLAND CA
91786-4910
US

V. Phone/Fax

Practice location:
  • Phone: 909-622-1235
  • Fax: 909-622-1960
Mailing address:
  • Phone: 909-622-1235
  • Fax: 909-622-1960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberPA61672
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: