Basic Information
| Provider Information | |||||||||
| NPI: | 1164586400 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CORDER | ||||||||
| FirstName: | FRED | ||||||||
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| NameSuffix: | JR. | ||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 946 SEVERN DR | ||||||||
| Address2: | |||||||||
| City: | COSHOCTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 438122737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7406224916 | ||||||||
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| Practice Location | |||||||||
| Address1: | 440 BROWNS LN | ||||||||
| Address2: | |||||||||
| City: | COSHOCTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 438122044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7406220332 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 50.000341 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 50.000341 | 01 | OH | PA-C LICENSE NUMBER | OTHER |