Provider Demographics
NPI:1982093126
Name:CORRELL, CHANDLER BROOKS (PA-C)
Entity Type:Individual
Prefix:
First Name:CHANDLER
Middle Name:BROOKS
Last Name:CORRELL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4747 W 29TH AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80212-1508
Mailing Address - Country:US
Mailing Address - Phone:704-618-5850
Mailing Address - Fax:
Practice Address - Street 1:12505 E. 16TH AVE, AIP2, 3RD FLOOR
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80045
Practice Address - Country:US
Practice Address - Phone:720-848-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-12
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-05474363A00000X
CO0005696363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1982093126Medicaid
NCNCM502AMedicare UPIN
NCNCM502BMedicare UPIN