Provider Demographics
NPI:1851357321
Name:WENTWORTH, CORINNE LEE (PA C)
Entity Type:Individual
Prefix:
First Name:CORINNE
Middle Name:LEE
Last Name:WENTWORTH
Suffix:
Gender:F
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 1:221 W COLORADO BLVD STE 525
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75208-2312
Mailing Address - Country:US
Mailing Address - Phone:214-960-5681
Mailing Address - Fax:214-820-3558
Practice Address - Street 1:221 W COLORADO BLVD STE 525
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75208-2312
Practice Address - Country:US
Practice Address - Phone:214-960-5681
Practice Address - Fax:214-960-5681
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02769363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX104345702Medicaid
TXP01173046OtherMEDICARE RAIL ROAD
TX104345702Medicaid
TX87N186Medicare ID - Type Unspecified