Healthcare Provider Details

I. General information

NPI: 1225864895
Provider Name (Legal Business Name): RANDOL ARIAS CORPORAN PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: RANDOL A CORPORAN PTA

II. Dates (important events)

Enumeration Date: 09/11/2024
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 GRESHAM DR
NORFOLK VA
23507-1904
US

IV. Provider business mailing address

5103 REGATTA POINTE RD
SUFFOLK VA
23435-3525
US

V. Phone/Fax

Practice location:
  • Phone: 757-388-3000
  • Fax:
Mailing address:
  • Phone: 843-271-0821
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2306606124
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: