Provider Demographics
NPI:1881138592
Name:CORBIN, TRACI (NP)
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:
Last Name:CORBIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 FURYS FERRY RD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30907-9059
Mailing Address - Country:US
Mailing Address - Phone:762-685-5501
Mailing Address - Fax:706-750-9229
Practice Address - Street 1:411 TOWN PARK BLVD
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3487
Practice Address - Country:US
Practice Address - Phone:706-854-2500
Practice Address - Fax:706-854-2534
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-14
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN261681208000000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003190470CMedicaid