Provider Demographics
NPI:1376670620
Name:BROWN, COREY DONYELL (PA)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:DONYELL
Last Name:BROWN
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 1:7924 CALEDONIA ST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22309-1006
Mailing Address - Country:US
Mailing Address - Phone:301-498-5990
Mailing Address - Fax:
Practice Address - Street 1:575 MAIN ST
Practice Address - Street 2:SUITE 351
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-4343
Practice Address - Country:US
Practice Address - Phone:301-498-5990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0003408363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC021528D14Medicare PIN