Provider Demographics
NPI:1679981641
Name:CORBETT FAMILY MEDICAL CENTER PLC
Entity type:Organization
Organization Name:CORBETT FAMILY MEDICAL CENTER PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:CRISTA
Authorized Official - Middle Name:
Authorized Official - Last Name:CORBETT
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:239-333-4100
Mailing Address - Street 1:4991 ROYAL GULF CIR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33966-7006
Mailing Address - Country:US
Mailing Address - Phone:239-333-4100
Mailing Address - Fax:239-333-4101
Practice Address - Street 1:4991 ROYAL GULF CIR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33966-7006
Practice Address - Country:US
Practice Address - Phone:239-333-4100
Practice Address - Fax:239-333-4101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-23
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106885363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA 9106885OtherMEDICAL LICENSE
FLOS7984OtherMEDICAL LICENSE