Provider Demographics
NPI:1033881073
Name:FORSYTH, COREY
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:
Last Name:FORSYTH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 INGHAM DR
Mailing Address - Street 2:
Mailing Address - City:STEVENS
Mailing Address - State:PA
Mailing Address - Zip Code:17578-9578
Mailing Address - Country:US
Mailing Address - Phone:717-690-1015
Mailing Address - Fax:
Practice Address - Street 1:28 INGHAM DR
Practice Address - Street 2:
Practice Address - City:STEVENS
Practice Address - State:PA
Practice Address - Zip Code:17578-9578
Practice Address - Country:US
Practice Address - Phone:717-690-1015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-28
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0007211207X00000X, 363AS0400X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty