Provider Demographics
NPI:1417995937
Name:KORENKE, ADAM SHANE (PA C)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:SHANE
Last Name:KORENKE
Suffix:
Gender:M
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 1:5201 HARRY HINES BLVD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75235-7708
Mailing Address - Country:US
Mailing Address - Phone:214-590-8000
Mailing Address - Fax:214-590-5843
Practice Address - Street 1:5201 HARRY HINES BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-7708
Practice Address - Country:US
Practice Address - Phone:214-590-8000
Practice Address - Fax:214-590-5843
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2017-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04554363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX303919003Medicaid
TX8G0144Medicare PIN
TX303919003Medicaid
TXQ35569Medicare UPIN