Provider Demographics
NPI:1740264092
Name:CORCORAN, MARYKATHRYN (CRNP)
Entity type:Individual
Prefix:MS
First Name:MARYKATHRYN
Middle Name:
Last Name:CORCORAN
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 SOUTH ALLEN ST.
Mailing Address - Street 2:SUITE 417-A
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16801
Mailing Address - Country:US
Mailing Address - Phone:814-238-2121
Mailing Address - Fax:814-238-0080
Practice Address - Street 1:315 SOUTH ALLEN ST.
Practice Address - Street 2:SUITE 417-A
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16801
Practice Address - Country:US
Practice Address - Phone:814-238-2121
Practice Address - Fax:814-238-0080
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-30
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP009695363LP0808X
PASP006933B363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA064255QLTMedicare UPIN