Provider Demographics
NPI:1164694717
Name:KORDUBA, RENEE MARIE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:RENEE
Middle Name:MARIE
Last Name:KORDUBA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:RENEE
Other - Middle Name:MARIE
Other - Last Name:VALLIERE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4055 FOX MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-7841
Mailing Address - Country:US
Mailing Address - Phone:330-721-4482
Mailing Address - Fax:
Practice Address - Street 1:18101 LORAIN AVE
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44111
Practice Address - Country:US
Practice Address - Phone:216-476-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-24
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH001429363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant