Provider Demographics
NPI:1063899540
Name:CORCORAN, JAMES P (DPT)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:P
Last Name:CORCORAN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX PH
Mailing Address - Street 2:
Mailing Address - City:CHINLE
Mailing Address - State:AZ
Mailing Address - Zip Code:86503-8000
Mailing Address - Country:US
Mailing Address - Phone:928-674-7166
Mailing Address - Fax:928-674-7705
Practice Address - Street 1:NAVAJO ROUTE 4
Practice Address - Street 2:
Practice Address - City:PINON
Practice Address - State:AZ
Practice Address - Zip Code:86510
Practice Address - Country:US
Practice Address - Phone:928-725-3220
Practice Address - Fax:928-725-3613
Is Sole Proprietor?:No
Enumeration Date:2015-05-04
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD23976225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD23976OtherSTATE LICENSE