MEDICARE: MR. ANGELO CORBIN SR. LSA

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
1	363AS0400X	Surgical Physician Assistant	SA0110	TX
2	363AS0400X	Surgical Physician Assistant

General Provider Information

NPI Number	:	1528039583
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ANGELO CORBIN SR. LSA

Provider Business Mailing Address
First Line	:	17534 SANDY CLIFFS DR.
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77090
Country	:	US
Telephone Number	:	281-798-6695
Fax Number	:

Provider Business Practice Location Address
First Line	:	17534 SANDY CLIFFS DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77090-2064
Country	:	US
Telephone Number	:	281-303-5870
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/29/2006
Last Update Date	:	10/14/2014

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