Provider Demographics
NPI:1467635169
Name:MENDIS, CORINNA LUISE (RPAC)
Entity Type:Individual
Prefix:
First Name:CORINNA
Middle Name:LUISE
Last Name:MENDIS
Suffix:
Gender:F
Credentials:RPAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:2500 NESCONSET HIGHWAY
Mailing Address - Street 2:BLDG 21C
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790
Mailing Address - Country:US
Mailing Address - Phone:631-246-8289
Mailing Address - Fax:631-246-8294
Practice Address - Street 1:2500 NESCONSET HWY
Practice Address - Street 2:BLDG 21C
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-2555
Practice Address - Country:US
Practice Address - Phone:631-246-8289
Practice Address - Fax:631-246-8294
Is Sole Proprietor?:No
Enumeration Date:2007-12-17
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY012299363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical