Provider Demographics
NPI:1184236226
Name:CORPUS, ANDREA ROSE
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:ROSE
Last Name:CORPUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:ROSE
Other - Last Name:MCKINNEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7617 GRAYLING CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28227-1200
Mailing Address - Country:US
Mailing Address - Phone:423-360-5246
Mailing Address - Fax:
Practice Address - Street 1:5501 EXECUTIVE CENTER DR STE 215
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28212-8823
Practice Address - Country:US
Practice Address - Phone:980-613-8312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-19
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-10924363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty