Provider Demographics
NPI:1336194208
Name:CORLEY, JOSHUA DERRELL (PA)
Entity Type:Individual
Prefix:MR
First Name:JOSHUA
Middle Name:DERRELL
Last Name:CORLEY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:902 ARLINGTON CTR
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-2883
Mailing Address - Country:US
Mailing Address - Phone:580-272-0025
Mailing Address - Fax:580-272-6659
Practice Address - Street 1:721 BETTER NOW PLZ
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-2279
Practice Address - Country:US
Practice Address - Phone:580-272-0025
Practice Address - Fax:580-272-6659
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPA1538363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK245617201OtherMEDICARE
OK20083400AMedicaid
OKPA1538OtherPA MEDICAL LICENSE
OKPA1538OtherPA MEDICAL LICENSE