Provider Demographics
NPI:1669921524
Name:DEBERRY-SEGUINE, COREY WAYNE (PA-C)
Entity type:Individual
Prefix:
First Name:COREY
Middle Name:WAYNE
Last Name:DEBERRY-SEGUINE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:COREY
Other - Middle Name:WAYNE
Other - Last Name:SEGUINE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:4915 E BASELINE RD STE 112
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-2966
Mailing Address - Country:US
Mailing Address - Phone:480-626-6600
Mailing Address - Fax:480-626-6604
Practice Address - Street 1:4915 E BASELINE RD STE 112
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2966
Practice Address - Country:US
Practice Address - Phone:480-626-6600
Practice Address - Fax:480-626-6604
Is Sole Proprietor?:No
Enumeration Date:2016-10-03
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6480363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant