Provider Demographics
NPI:1609802321
Name:CORDER, GARY S (PA-C)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:S
Last Name:CORDER
Suffix:
Gender:M
Credentials:PA-C
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Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:650 PETER JEFFERSON PKWY
Mailing Address - Street 2:STE 100
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22911-8844
Mailing Address - Country:US
Mailing Address - Phone:434-293-4072
Mailing Address - Fax:434-293-4265
Practice Address - Street 1:650 PETER JEFFERSON PKWY
Practice Address - Street 2:STE 100
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22911-8844
Practice Address - Country:US
Practice Address - Phone:434-293-4072
Practice Address - Fax:434-293-4265
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0110001357363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P33065Medicare UPIN
VAP01144331Medicare PIN
P33065Medicare UPIN