Provider Demographics
NPI:1205198454
Name:MOBERG, CORBIN
Entity Type:Individual
Prefix:
First Name:CORBIN
Middle Name:
Last Name:MOBERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9627 SUPERIOR CT NE
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-8528
Mailing Address - Country:US
Mailing Address - Phone:509-760-0399
Mailing Address - Fax:
Practice Address - Street 1:605 S COOLIDGE ST
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-1893
Practice Address - Country:US
Practice Address - Phone:509-793-9785
Practice Address - Fax:509-764-0344
Is Sole Proprietor?:No
Enumeration Date:2012-06-13
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60285521363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8955335Medicare PIN