Provider Demographics
NPI:1285687129
Name:CORTA, PETER (PA)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:CORTA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 RIVER NORTH BLVD
Mailing Address - Street 2:
Mailing Address - City:STEPHENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76401-1803
Mailing Address - Country:US
Mailing Address - Phone:254-968-6051
Mailing Address - Fax:254-968-4950
Practice Address - Street 1:150 RIVER NORTH BLVD
Practice Address - Street 2:
Practice Address - City:STEPHENVILLE
Practice Address - State:TX
Practice Address - Zip Code:76401-1803
Practice Address - Country:US
Practice Address - Phone:254-968-6051
Practice Address - Fax:254-968-4950
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04189363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00310316OtherRAILROAD MEDICARE
TX017584601Medicaid
TX017584601Medicaid
TXP00310316OtherRAILROAD MEDICARE
TX8G5305Medicare ID - Type UnspecifiedPART B MEDICARE