Provider Demographics
NPI:1891500807
Name:CORPUS, AYLWYN DALE MALBAS
Entity type:Individual
Prefix:
First Name:AYLWYN DALE
Middle Name:MALBAS
Last Name:CORPUS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 LIBERTY VIEW LN
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502-2291
Mailing Address - Country:US
Mailing Address - Phone:870-814-0938
Mailing Address - Fax:
Practice Address - Street 1:306 LIBERTY VIEW LN
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-2291
Practice Address - Country:US
Practice Address - Phone:870-814-0938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-08
Last Update Date:2025-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program