Provider Demographics
NPI:1770809766
Name:CORPAS, MARY JANE
Entity type:Individual
Prefix:
First Name:MARY JANE
Middle Name:
Last Name:CORPAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 LIBER BLVD
Mailing Address - Street 2:
Mailing Address - City:FARMINGVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11738-1133
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22 LIBER BLVD
Practice Address - Street 2:
Practice Address - City:FARMINGVILLE
Practice Address - State:NY
Practice Address - Zip Code:11738-1133
Practice Address - Country:US
Practice Address - Phone:631-696-2069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-15
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY349247163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse