Basic Information
| Provider Information | |||||||||
| NPI: | 1790767333 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CORCORAN-SMITH | ||||||||
| FirstName: | TONI | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1520 | ||||||||
| Address2: | |||||||||
| City: | THE DALLES | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970583388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412965256 | ||||||||
| FaxNumber: | 5412965451 | ||||||||
| Practice Location | |||||||||
| Address1: | 551 LONE PINE BLVD | ||||||||
| Address2: | |||||||||
| City: | THE DALLES | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970581520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412965256 | ||||||||
| FaxNumber: | 5412965451 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2005 | ||||||||
| LastUpdateDate: | 09/21/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 200350101NP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 218103 | 05 | OR | MEDICAID | 297450 | 05 | OR | MEDICAID |