Provider Demographics
NPI:1003096959
Name:PAGE, COREY A (PAC)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:A
Last Name:PAGE
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:539 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82007-1591
Mailing Address - Country:US
Mailing Address - Phone:307-286-8236
Mailing Address - Fax:
Practice Address - Street 1:2030 BLUEGRASS CIR
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-7328
Practice Address - Country:US
Practice Address - Phone:307-286-8236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-08
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY378363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant