Provider Demographics
NPI:1497843643
Name:CORDEN, TODD MICHAEL (PA-C)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:MICHAEL
Last Name:CORDEN
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 1:2624 EXECUTIVE DR # 118
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34292-2603
Mailing Address - Country:US
Mailing Address - Phone:248-756-1934
Mailing Address - Fax:
Practice Address - Street 1:2624 EXECUTIVE DR # 118
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34292-2603
Practice Address - Country:US
Practice Address - Phone:248-756-1934
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9117438363A00000X, 363AM0700X
MI5601003596363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMC0902076OtherFEDERAL DEA