Healthcare Provider Details

I. General information

NPI: 1689148306
Provider Name (Legal Business Name): VICTORIA CORRELL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VICTORIA CRITTENDEN PA-C

II. Dates (important events)

Enumeration Date: 01/15/2019
Last Update Date: 05/19/2021
Certification Date: 05/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4647 MANATEE AVE W
BRADENTON FL
34209-3816
US

IV. Provider business mailing address

367 S GULPH RD ATTN IPM CREDENTIALING
KING OF PRUSSIA PA
19406-3121
US

V. Phone/Fax

Practice location:
  • Phone: 941-745-5999
  • Fax: 941-745-3555
Mailing address:
  • Phone: 941-745-5999
  • Fax: 941-745-3555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9111971
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: