Basic Information
| Provider Information | |||||||||
| NPI: | 1477831196 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCANN | ||||||||
| FirstName: | COREY | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CANP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1747 IMPERIAL BLVD | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706055362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3377217236 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1717 OAK PARK BLVD FL 3 | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706018990 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374944900 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2011 | ||||||||
| LastUpdateDate: | 09/13/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | AP06636 | LA | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 163WX0800X | RN114345 | LA | N | Nursing Service Providers | Registered Nurse | Orthopedic |
No ID Information.