Provider Demographics
NPI:1083697064
Name:ERNST, COREY LYNN (PA C)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:LYNN
Last Name:ERNST
Suffix:
Gender:M
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 CRESCENT DR
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82007-9107
Mailing Address - Country:US
Mailing Address - Phone:307-630-2973
Mailing Address - Fax:307-638-0394
Practice Address - Street 1:2003 BLUEGRASS CIRCLE
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009
Practice Address - Country:US
Practice Address - Phone:307-634-4357
Practice Address - Fax:307-634-7773
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY187363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY314332OtherBLUE CROSS BLUE SHIELD
WY116713800Medicaid
WY187OtherSTATE LICENSE
WY41CLE01OtherSUBSTANCE CONTROL
WY314332OtherBLUE CROSS BLUE SHIELD
307386Medicare ID - Type Unspecified