Basic Information
| Provider Information | |||||||||
| NPI: | 1417995937 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KORENKE | ||||||||
| FirstName: | ADAM | ||||||||
| MiddleName: | SHANE | ||||||||
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| Credential: | PA C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5201 HARRY HINES BLVD | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752357708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2145908000 | ||||||||
| FaxNumber: | 2145905843 | ||||||||
| Practice Location | |||||||||
| Address1: | 5201 HARRY HINES BLVD | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752357708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2145908000 | ||||||||
| FaxNumber: | 2145905843 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 08/30/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA04554 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 303919003 | 05 | TX | MEDICAID |