Provider Demographics
NPI:1902420938
Name:CORRIVEAU, DENISE JEAN (PA)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:JEAN
Last Name:CORRIVEAU
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 E HURON ST STE 1-200
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2909
Mailing Address - Country:US
Mailing Address - Phone:312-503-1851
Mailing Address - Fax:
Practice Address - Street 1:8008 FROST ST STE 200
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4207
Practice Address - Country:US
Practice Address - Phone:858-292-7527
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-05
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAPA61332363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program