Provider Demographics
NPI:1639800998
Name:CORCORAN, ALYSSA
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:CORCORAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7116 DORNOUGH LN
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34202-4004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:221 MAHALANI ST
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-2526
Practice Address - Country:US
Practice Address - Phone:808-244-9056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-18
Last Update Date:2022-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL32836208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation