Provider Demographics
NPI:1366590937
Name:CORPUZ, REBECCA LEIGH
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:LEIGH
Last Name:CORPUZ
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 1:9735 FOREST CREEK DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46835-9001
Mailing Address - Country:US
Mailing Address - Phone:260-444-5254
Mailing Address - Fax:
Practice Address - Street 1:885 CONNEXION WAY
Practice Address - Street 2:SUITE 200
Practice Address - City:COLUMBIA CITY
Practice Address - State:IN
Practice Address - Zip Code:46725
Practice Address - Country:US
Practice Address - Phone:260-248-9268
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000911A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant