Basic Information
| Provider Information | |||||||||
| NPI: | 1174000566 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CORK | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | WAYNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CPRP, BS | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2201 IRONWOOD PL | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838142670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087694222 | ||||||||
| FaxNumber: | 2087710628 | ||||||||
| Practice Location | |||||||||
| Address1: | 2201 IRONWOOD PL | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838142670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087694222 | ||||||||
| FaxNumber: | 2087710628 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2018 | ||||||||
| LastUpdateDate: | 07/27/2018 | ||||||||
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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 | 174400000X | Y | Other Service Providers | Specialist |
No ID Information.