Provider Demographics
NPI:1003468190
Name:HERZOG, CORY (DNP,CRNA)
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:
Last Name:HERZOG
Suffix:
Gender:M
Credentials:DNP,CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3495 BAILEY AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14215-1129
Mailing Address - Country:US
Mailing Address - Phone:716-834-9200
Mailing Address - Fax:
Practice Address - Street 1:3495 BAILEY AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215-1129
Practice Address - Country:US
Practice Address - Phone:716-834-9200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-10
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY647231367500000X
TX1130963367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty