Provider Demographics
NPI:1053461889
Name:CORBETT, PAUL M (CRNA)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:M
Last Name:CORBETT
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 37090
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-3090
Mailing Address - Country:US
Mailing Address - Phone:703-295-9360
Mailing Address - Fax:703-295-9369
Practice Address - Street 1:3998 FAIR RIDGE DRIVE
Practice Address - Street 2:SUITE 320
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-2921
Practice Address - Country:US
Practice Address - Phone:703-295-9360
Practice Address - Fax:703-295-9369
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC157355163W00000X
NC072157367500000X
VA0024171123367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAPENDINGMedicaid
NC5903562Medicaid
VAPENDINGMedicare PIN
NC5903562Medicaid