Provider Demographics
NPI:1063489987
Name:CORPUS, PRIMILINA A (MD)
Entity Type:Individual
Prefix:DR
First Name:PRIMILINA
Middle Name:A
Last Name:CORPUS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 934
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:KY
Mailing Address - Zip Code:42419-0934
Mailing Address - Country:US
Mailing Address - Phone:270-827-9701
Mailing Address - Fax:270-831-7818
Practice Address - Street 1:1305 N ELM ST
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:KY
Practice Address - Zip Code:42420-2783
Practice Address - Country:US
Practice Address - Phone:270-827-9701
Practice Address - Fax:270-831-7818
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY17829207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64178296Medicaid
0634401Medicare ID - Type Unspecified
KY64178296Medicaid