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NPI Code Detail

MEDICARE: JONATHAN P CORLEY PA-C

MEDICARE: JONATHAN P CORLEY PA-C
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363A00000XPhysician AssistantLA

General Provider Information

NPI Number : 1356696280
Entity Type Code : Individual
Provider Name (Legal Business Name) : JONATHAN P CORLEY PA-C
Provider Business Mailing Address
First Line : 224 PECAN PARK AVE
Second Line :
City : ALEXANDRIA
State : LA
Zip : 71303-3308
Country : US
Telephone Number : 318-427-7900
Fax Number : 318-427-7901
Provider Business Practice Location Address
First Line : 4100 EMBASSY DR SE
Second Line : SUITE 200
City : GRAND RAPIDS
State : MI
Zip : 49546-2416
Country : US
Telephone Number : 616-975-1845
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/17/2012
Last Update Date : 07/24/2012

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Directions to “ JONATHAN P CORLEY PA-C” Practice Location

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