Provider Demographics
NPI:1053682229
Name:CORY, JOHN BRANDON (CRNA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:BRANDON
Last Name:CORY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:BRANDON
Other - Middle Name:
Other - Last Name:CORY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:650 ADDISON AVE W
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-5444
Mailing Address - Country:US
Mailing Address - Phone:208-734-7362
Mailing Address - Fax:
Practice Address - Street 1:801 POLE LINE RD W
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301
Practice Address - Country:US
Practice Address - Phone:208-814-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-20
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT102238367500000X
IDRNA-819A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered