Provider Demographics
NPI:1023151081
Name:CORSILLES, MICHAEL (PA-C)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:CORSILLES
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 1:2100 116TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-3016
Mailing Address - Country:US
Mailing Address - Phone:425-467-1314
Mailing Address - Fax:
Practice Address - Street 1:8639 36TH AVE SW
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98126-3609
Practice Address - Country:US
Practice Address - Phone:206-380-5202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANT00001187175F00000X
WAPA60191026363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No175F00000XOther Service ProvidersNaturopathGroup - Multi-Specialty