Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LC1500X | Nurse Practitioner - Community Health | 093007080N1 | OR |
NPI | 1851372643 |
---|---|
Provider Name | Mark Corey |
First Address | Moro, OR 97039-0186 |
Second Address | Moro, OR 97039-3080 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/11/2005 |
Last Update Date | 27/03/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
023015 | (05) | OR |
P84216 | (02) | OR |