Provider Demographics
NPI:1851060172
Name:CAMPBELL, COREY LEE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:COREY
Middle Name:LEE
Last Name:CAMPBELL
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 1:526 ROUND RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40977-7008
Mailing Address - Country:US
Mailing Address - Phone:859-409-6154
Mailing Address - Fax:
Practice Address - Street 1:526 ROUND RIDGE RD
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:KY
Practice Address - Zip Code:40977-7008
Practice Address - Country:US
Practice Address - Phone:859-409-6154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-09
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTC162363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant