Healthcare Provider Details

I. General information

NPI: 1073506275
Provider Name (Legal Business Name): CORINNE L WEIS PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CORINNE L ANDERSON PA

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 04/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6220 W MAIN ST
KALAMAZOO MI
49009-8925
US

IV. Provider business mailing address

6220 W MAIN ST
KALAMAZOO MI
49009-8925
US

V. Phone/Fax

Practice location:
  • Phone: 269-276-4744
  • Fax: 269-353-5856
Mailing address:
  • Phone: 269-276-4744
  • Fax: 269-353-5856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1917
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601008155
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: