Basic Information
Provider Information
NPI: 1659526044
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: WASE
FirstName: CORI
MiddleName: M
NamePrefix:  
NameSuffix:  
Credential: MSPT
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName: WASE
OtherFirstName: CORI
OtherMiddleName: M
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential: MSPT
OtherLastNameType: 1
Mailing Information
Address1: 747 MADISON AVE
Address2: STE 1
City: ALBANY
State: NY
PostalCode: 122083392
CountryCode: US
TelephoneNumber: 5184892524
FaxNumber: 5184893617
Practice Location
Address1: 747 MADISON AVE
Address2: SUITE 1
City: ALBANY
State: NY
PostalCode: 122083385
CountryCode: US
TelephoneNumber: 5184432279
FaxNumber: 5184437246
Other Information
ProviderEnumerationDate: 11/26/2008
LastUpdateDate: 12/13/2016
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225100000X030881-1NYN Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist 
225100000X030881NYY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist 

No ID Information.


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