Basic Information
| Provider Information | |||||||||
| NPI: | 1902185747 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CORDES | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | FILE 56765 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900746765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024063860 | ||||||||
| FaxNumber: | 6024066132 | ||||||||
| Practice Location | |||||||||
| Address1: | 7727 W DEER VALLEY RD | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | PEORIA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853822116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024061200 | ||||||||
| FaxNumber: | 6024061212 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2011 | ||||||||
| LastUpdateDate: | 04/23/2012 | ||||||||
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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 | 4939 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 648303 | 05 | AZ | MEDICAID |