Provider Demographics
NPI:1356696280
Name:CORLEY, JONATHAN P (PA-C)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:P
Last Name:CORLEY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:224 PECAN PARK AVE
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71303-3308
Mailing Address - Country:US
Mailing Address - Phone:318-427-7900
Mailing Address - Fax:318-427-7901
Practice Address - Street 1:4100 EMBASSY DR SE
Practice Address - Street 2:SUITE 200
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-2416
Practice Address - Country:US
Practice Address - Phone:616-975-1845
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-17
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant