Provider Demographics
NPI:1972544575
Name:GENTEEL, COREY ADRIAN (PAC)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:ADRIAN
Last Name:GENTEEL
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 POCONO CMNS STE 101
Mailing Address - Street 2:
Mailing Address - City:STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18360-7599
Mailing Address - Country:US
Mailing Address - Phone:570-827-9955
Mailing Address - Fax:570-872-9255
Practice Address - Street 1:101 POCONO CMNS STE 101
Practice Address - Street 2:
Practice Address - City:STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18360-7599
Practice Address - Country:US
Practice Address - Phone:570-872-9955
Practice Address - Fax:570-872-9255
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA003405L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP00148935OtherRAILROAD MEDICARE
PA081129N46Medicare PIN