Provider Demographics
NPI:1972577088
Name:CORBETT, JAMES T (PA-C)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:T
Last Name:CORBETT
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 1:36 KLONDIKE RD
Mailing Address - Street 2:
Mailing Address - City:REPUBLIC
Mailing Address - State:WA
Mailing Address - Zip Code:99166-9701
Mailing Address - Country:US
Mailing Address - Phone:509-775-3153
Mailing Address - Fax:509-775-8929
Practice Address - Street 1:1810 MESQUITE AVE STE B
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5886
Practice Address - Country:US
Practice Address - Phone:928-453-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003454363A00000X
AZ5180363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8349417Medicaid
S33209Medicare UPIN
WA8349417Medicaid