Provider Demographics
NPI:1689148306
Name:CORRELL, VICTORIA (PA-C)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:CORRELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:
Other - Last Name:CRITTENDEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:367 S GULPH RD
Mailing Address - Street 2:ATTN IPM CREDENTIALING
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-3121
Mailing Address - Country:US
Mailing Address - Phone:941-745-5999
Mailing Address - Fax:941-745-3555
Practice Address - Street 1:4647 MANATEE AVE W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-3816
Practice Address - Country:US
Practice Address - Phone:941-745-5999
Practice Address - Fax:941-745-3555
Is Sole Proprietor?:No
Enumeration Date:2019-01-15
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9111971363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant