Provider Demographics
NPI:1124345012
Name:CORSON, KEVIN D (LPN)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:D
Last Name:CORSON
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1467 LICK ST
Mailing Address - Street 2:
Mailing Address - City:MORAVIA
Mailing Address - State:NY
Mailing Address - Zip Code:13118-2358
Mailing Address - Country:US
Mailing Address - Phone:607-745-0381
Mailing Address - Fax:
Practice Address - Street 1:1467 LICK ST
Practice Address - Street 2:
Practice Address - City:MORAVIA
Practice Address - State:NY
Practice Address - Zip Code:13118-2358
Practice Address - Country:US
Practice Address - Phone:607-745-0381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-30
Last Update Date:2010-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY286006164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse