Provider Demographics
NPI:1760112734
Name:TODD, CORBIN E (PA-C)
Entity Type:Individual
Prefix:
First Name:CORBIN
Middle Name:E
Last Name:TODD
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 1:515 N CLARKSON ST APT 1102
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80218-3249
Mailing Address - Country:US
Mailing Address - Phone:303-726-9204
Mailing Address - Fax:
Practice Address - Street 1:914 S SCHEUBER RD
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-9027
Practice Address - Country:US
Practice Address - Phone:303-726-9204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-13
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WAPA61469366363A00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty