Basic Information
Provider Information | |||||||||
NPI: | 1093706558 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HALL | ||||||||
FirstName: | CORY | ||||||||
MiddleName: | T | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PAC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 529 | ||||||||
Address2: |   | ||||||||
City: | ZEPHYR COVE | ||||||||
State: | NV | ||||||||
PostalCode: | 894480529 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7755888938 | ||||||||
FaxNumber: | 7755888930 | ||||||||
Practice Location | |||||||||
Address1: | 1139 3RD ST | ||||||||
Address2: |   | ||||||||
City: | SOUTH LAKE TAHOE | ||||||||
State: | CA | ||||||||
PostalCode: | 961503465 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5305413100 | ||||||||
FaxNumber: | 5305413016 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/03/2005 | ||||||||
LastUpdateDate: | 11/16/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA15806 | CA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363A00000X | PA678 | NV | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | CC1490 | 01 | NV | BCBS | OTHER |