Provider Demographics
NPI:1609142850
Name:CORLEW, MERCEDES DENISE (PA)
Entity Type:Individual
Prefix:
First Name:MERCEDES
Middle Name:DENISE
Last Name:CORLEW
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18610 BOULDER AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92508-9711
Mailing Address - Country:US
Mailing Address - Phone:951-776-2351
Mailing Address - Fax:
Practice Address - Street 1:31700 TEMECULA PKWY
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92592-5896
Practice Address - Country:US
Practice Address - Phone:951-331-2200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-31
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA22217363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant