Provider Demographics
NPI:1376299651
Name:PLACE, CORBY
Entity Type:Individual
Prefix:
First Name:CORBY
Middle Name:
Last Name:PLACE
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 1:1621 ANTIOCH CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:ALVATON
Mailing Address - State:KY
Mailing Address - Zip Code:42122-9606
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1201 S 7TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85007-3913
Practice Address - Country:US
Practice Address - Phone:602-416-7600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-25
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant