Basic Information
| Provider Information | |||||||||
| NPI: | 1326297888 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CORPORAN | ||||||||
| FirstName: | JOSE | ||||||||
| MiddleName: | BIENVENIDO | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15 LAFAYETTE ST | ||||||||
| Address2: | |||||||||
| City: | MILTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021862602 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 199 REEDSDALE RD | ||||||||
| Address2: | |||||||||
| City: | MILTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021863926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176964600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2008 | ||||||||
| LastUpdateDate: | 09/09/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2091 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.