Provider Demographics
NPI:1225864895
Name:CORPORAN, RANDOL ARIAS (PTA)
Entity type:Individual
Prefix:MR
First Name:RANDOL
Middle Name:ARIAS
Last Name:CORPORAN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:RANDOL
Other - Middle Name:A
Other - Last Name:CORPORAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PTA
Mailing Address - Street 1:5103 REGATTA POINTE RD
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-3525
Mailing Address - Country:US
Mailing Address - Phone:843-271-0821
Mailing Address - Fax:
Practice Address - Street 1:600 GRESHAM DR
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1904
Practice Address - Country:US
Practice Address - Phone:757-388-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-11
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306606124225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant