Basic Information
| Provider Information | |||||||||
| NPI: | 1528460748 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHARP | ||||||||
| FirstName: | CORY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3400 GRIFFIN AVE | ||||||||
| Address2: | |||||||||
| City: | PEKIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 615546246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3093474277 | ||||||||
| FaxNumber: | 3093474388 | ||||||||
| Practice Location | |||||||||
| Address1: | 3400 GRIFFIN AVE | ||||||||
| Address2: | |||||||||
| City: | PEKIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 615546246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3093474277 | ||||||||
| FaxNumber: | 3093474388 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2014 | ||||||||
| LastUpdateDate: | 09/18/2014 | ||||||||
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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 | 085005223 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.