Provider Demographics
NPI:1326391509
Name:CORCORAN, KELLY ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:CORCORAN
Suffix:
Gender:F
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 1:236 NEWPINE DR
Mailing Address - Street 2:
Mailing Address - City:CLEVES
Mailing Address - State:OH
Mailing Address - Zip Code:45002-2383
Mailing Address - Country:US
Mailing Address - Phone:513-608-3532
Mailing Address - Fax:
Practice Address - Street 1:5520 CHEVIOT RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45247
Practice Address - Country:US
Practice Address - Phone:513-853-1300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-24
Last Update Date:2018-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC04907363AM0700X
OH50.005109RX363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical