Provider Demographics
NPI:1245272046
Name:CORPUS, JESSIE E (PA)
Entity type:Individual
Prefix:
First Name:JESSIE
Middle Name:E
Last Name:CORPUS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 E WALKER ST STE A
Mailing Address - Street 2:
Mailing Address - City:ORLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95963-2222
Mailing Address - Country:US
Mailing Address - Phone:530-865-4400
Mailing Address - Fax:530-865-7285
Practice Address - Street 1:750 E WALKER ST STE A
Practice Address - Street 2:
Practice Address - City:ORLAND
Practice Address - State:CA
Practice Address - Zip Code:95963-2222
Practice Address - Country:US
Practice Address - Phone:530-865-4400
Practice Address - Fax:530-865-7285
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA12348363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA058922Medicare Oscar/Certification
CA0PA123480Medicare ID - Type Unspecified
CA058961Medicare Oscar/Certification
CA553909Medicare Oscar/Certification
CAFT020 X/Y/ZMedicare PIN