Provider Demographics
NPI:1043949126
Name:CORYELL, SAMUEL (PA-C)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:CORYELL
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 1:2600 MEADOW RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40205-2222
Mailing Address - Country:US
Mailing Address - Phone:502-494-0949
Mailing Address - Fax:
Practice Address - Street 1:3605 FERN VALLEY RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40219-1916
Practice Address - Country:US
Practice Address - Phone:502-964-4889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-06
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTC222363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant