Provider Demographics
NPI:1821820168
Name:KORBUT, SELENA MICHELLE
Entity type:Individual
Prefix:
First Name:SELENA
Middle Name:MICHELLE
Last Name:KORBUT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:370 QUENTIN DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78201-3732
Mailing Address - Country:US
Mailing Address - Phone:210-643-6318
Mailing Address - Fax:
Practice Address - Street 1:3305 E FRY BLVD
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-2990
Practice Address - Country:US
Practice Address - Phone:520-515-2930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-15
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1103324163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse