Basic Information
| Provider Information | |||||||||
| NPI: | 1083697064 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ERNST | ||||||||
| FirstName: | COREY | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | PA C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1110 CRESCENT DR | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820079107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076302973 | ||||||||
| FaxNumber: | 3076380394 | ||||||||
| Practice Location | |||||||||
| Address1: | 2003 BLUEGRASS CIRCLE | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 82009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076344357 | ||||||||
| FaxNumber: | 3076347773 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2005 | ||||||||
| LastUpdateDate: | 10/02/2007 | ||||||||
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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 | 187 | WY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 314332 | 01 | WY | BLUE CROSS BLUE SHIELD | OTHER | 116713800 | 05 | WY | MEDICAID | 187 | 01 | WY | STATE LICENSE | OTHER | 41CLE01 | 01 | WY | SUBSTANCE CONTROL | OTHER |