Basic Information
| Provider Information | |||||||||
| NPI: | 1992825152 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STANLEY | ||||||||
| FirstName: | CORY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5730 OGEECHEE RD | ||||||||
| Address2: | SUITE 192 | ||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314059521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9122011140 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5730 OGEECHEE RD | ||||||||
| Address2: | SUITE 192 | ||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314059521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9122011140 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2007 | ||||||||
| LastUpdateDate: | 12/17/2014 | ||||||||
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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 | 005034 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 567447065A | 05 | GA | MEDICAID | 567447065F | 01 | GA | MEDICAID ID FOR URGENTONE | OTHER | 0580PA | 01 | SC | MEDICAID ID FOR URGENTONE | OTHER | GPA9002 | 01 | SC | MEDICAID GROUP ID FOR URGENTONE | OTHER | 567447065D | 05 | GA | MEDICAID | 511I970040 | 01 | GA | MEDICARE ID FOR URGENTONE | OTHER | P00441750 | 01 | GA | RR MEDICARE ID FOR URGENTONE | OTHER | 567447065 | 05 | GA | MEDICAID | 567447065C | 05 | GA | MEDICAID | GPA892 | 01 | SC | MEDICAID GROUP ID FOR URGENTONE | OTHER | 01061992 | 01 | GA | AMERIGROUP | OTHER | 567447065B | 05 | GA | MEDICAID | 567447065E | 01 | GA | MEDICAID ID FOR URGENTONE | OTHER |