Basic Information
| Provider Information | |||||||||
| NPI: | 1932456423 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CORRALES | ||||||||
| FirstName: | JOSSUE | ||||||||
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| Credential: | ARNP, MSN, NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5605 NW 82ND AVE | ||||||||
| Address2: | |||||||||
| City: | DORAL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331664000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056855688 | ||||||||
| FaxNumber: | 7866185307 | ||||||||
| Practice Location | |||||||||
| Address1: | 4888 NW 183RD ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | MIAMI GARDENS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330552939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056855688 | ||||||||
| FaxNumber: | 3056239459 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2012 | ||||||||
| LastUpdateDate: | 04/08/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 9310329 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 011847100 | 05 | FL | MEDICAID |