Basic Information
| Provider Information | |||||||||
| NPI: | 1235219676 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CORBOY | ||||||||
| FirstName: | JANE | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1620 E 12TH ST | ||||||||
| Address2: | PO BOX 1520 | ||||||||
| City: | THE DALLES | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970583213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412969151 | ||||||||
| FaxNumber: | 5412969156 | ||||||||
| Practice Location | |||||||||
| Address1: | 1620 E 12TH ST | ||||||||
| Address2: | |||||||||
| City: | THE DALLES | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970583213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412969151 | ||||||||
| FaxNumber: | 5412969156 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 11/13/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | G3248 | TX | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD150490 | OR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 137841611 | 05 | TX | MEDICAID | 137841605 | 05 | TX | MEDICAID | 218112 | 05 | OR | MEDICAID |