Provider Demographics
NPI:1073506275
Name:WEIS, CORINNE L (PA)
Entity Type:Individual
Prefix:
First Name:CORINNE
Middle Name:L
Last Name:WEIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CORINNE
Other - Middle Name:L
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:6220 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-8925
Mailing Address - Country:US
Mailing Address - Phone:269-276-4744
Mailing Address - Fax:269-353-5856
Practice Address - Street 1:6220 W MAIN ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-8925
Practice Address - Country:US
Practice Address - Phone:269-276-4744
Practice Address - Fax:269-353-5856
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1917363AM0700X
MI5601008155363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q43390Medicare UPIN