Provider Demographics
NPI:1417020314
Name:CORLEY, RICHARD A (PA)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:A
Last Name:CORLEY
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 1:10820 MARVIN E. JONES BLVD.
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:FL
Mailing Address - Zip Code:32060
Mailing Address - Country:US
Mailing Address - Phone:386-658-5300
Mailing Address - Fax:386-658-5130
Practice Address - Street 1:10820 MARVIN E JONES BLVD
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:FL
Practice Address - Zip Code:32060
Practice Address - Country:US
Practice Address - Phone:386-658-5300
Practice Address - Fax:386-658-5130
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2009-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102574363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMEDICAIDMedicaid
FLMEDICAIDMedicaid
MEDICAREMedicare ID - Type UnspecifiedU4692Z