Healthcare Provider Details

I. General information

NPI: 1457040222
Provider Name (Legal Business Name): CORBIN ADRA LEWIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2023
Last Update Date: 05/05/2023
Certification Date: 04/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2311 STATE ROAD 3
GREENSBURG IN
47240-9526
US

IV. Provider business mailing address

4196 HIGHWAY 62 412 STE A
HARDY AR
72542-8002
US

V. Phone/Fax

Practice location:
  • Phone: 765-307-7146
  • Fax:
Mailing address:
  • Phone: 479-388-0446
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number28236924A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: