Basic Information
| Provider Information | |||||||||
| NPI: | 1811090129 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOOD | ||||||||
| FirstName: | COREY | ||||||||
| MiddleName: | D. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4900 S MONACO ST STE 210 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802373487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3032092503 | ||||||||
| FaxNumber: | 3037610803 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 E HAMPDEN AVE STE 515 | ||||||||
| Address2: | |||||||||
| City: | ENGLEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801133880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3032092503 | ||||||||
| FaxNumber: | 3037610803 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2006 | ||||||||
| LastUpdateDate: | 01/27/2022 | ||||||||
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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 | 085-002802 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 3075 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 40929701 | 05 | CO | MEDICAID |