Provider Demographics
NPI:1154040178
Name:MAXWELL, CORINNE ERICA (PA-C)
Entity type:Individual
Prefix:MRS
First Name:CORINNE
Middle Name:ERICA
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CORINNE
Other - Middle Name:ERICA
Other - Last Name:BLAINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1230 E ARROW HWY
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4910
Mailing Address - Country:US
Mailing Address - Phone:909-622-1235
Mailing Address - Fax:909-622-1960
Practice Address - Street 1:1230 E ARROW HWY
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4910
Practice Address - Country:US
Practice Address - Phone:909-622-1235
Practice Address - Fax:909-622-1960
Is Sole Proprietor?:No
Enumeration Date:2022-08-23
Last Update Date:2024-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA61672208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics