Provider Demographics
NPI:1194163121
Name:PRESTIDGE, JOSEPH CORBIN (PA-C)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:CORBIN
Last Name:PRESTIDGE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18540 WHITE OAK DR
Mailing Address - Street 2:
Mailing Address - City:PRAIRIEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70769-3737
Mailing Address - Country:US
Mailing Address - Phone:225-802-8030
Mailing Address - Fax:
Practice Address - Street 1:18540 WHITE OAK DR
Practice Address - Street 2:
Practice Address - City:PRAIRIEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70769-3737
Practice Address - Country:US
Practice Address - Phone:225-802-8030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-12
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA.200633363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant