Provider Demographics
NPI:1184658627
Name:CORBITT, SHANE A (PA-C)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:A
Last Name:CORBITT
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 1:1905 ANN ST
Mailing Address - Street 2:
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26101-2504
Mailing Address - Country:US
Mailing Address - Phone:304-424-4150
Mailing Address - Fax:304-424-4151
Practice Address - Street 1:1905 ANN ST
Practice Address - Street 2:
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26101-2504
Practice Address - Country:US
Practice Address - Phone:304-424-4150
Practice Address - Fax:304-424-4151
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV01164363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
COPA26411Medicare ID - Type Unspecified