Basic Information
| Provider Information | |||||||||
| NPI: | 1023311263 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WRIGHT | ||||||||
| FirstName: | COREY | ||||||||
| MiddleName: | DOUGLAS | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2801 PURCELL ST | ||||||||
| Address2: | SUITE 1400 | ||||||||
| City: | BRIGHTON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806013551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036599700 | ||||||||
| FaxNumber: | 3035588222 | ||||||||
| Practice Location | |||||||||
| Address1: | 6161 S YALE AVE | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741361902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184941805 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2010 | ||||||||
| LastUpdateDate: | 07/06/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 1985 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 200139220A | 05 | OK | MEDICAID |