Provider Demographics
NPI:1063403038
Name:FOGLE, CORINNE E (PA-C)
Entity type:Individual
Prefix:MRS
First Name:CORINNE
Middle Name:E
Last Name:FOGLE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CORINNE
Other - Middle Name:
Other - Last Name:CONNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 127
Mailing Address - Street 2:303 EAST STREET
Mailing Address - City:GRINNELL
Mailing Address - State:IA
Mailing Address - Zip Code:50112-0127
Mailing Address - Country:US
Mailing Address - Phone:641-527-2929
Mailing Address - Fax:641-527-2922
Practice Address - Street 1:303 EAST ST
Practice Address - Street 2:
Practice Address - City:GRINNELL
Practice Address - State:IA
Practice Address - Zip Code:50112-2557
Practice Address - Country:US
Practice Address - Phone:641-527-2929
Practice Address - Fax:641-527-2922
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001334363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAP27388Medicare UPIN
IAI15980Medicare ID - Type Unspecified