Provider Demographics
NPI:1093587149
Name:HOUGHTLING, COREY
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:
Last Name:HOUGHTLING
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 1:5688 W WAUTOMA BEACH RD
Mailing Address - Street 2:
Mailing Address - City:HILTON
Mailing Address - State:NY
Mailing Address - Zip Code:14468-9126
Mailing Address - Country:US
Mailing Address - Phone:585-944-6317
Mailing Address - Fax:
Practice Address - Street 1:5688 W WAUTOMA BEACH RD
Practice Address - Street 2:
Practice Address - City:HILTON
Practice Address - State:NY
Practice Address - Zip Code:14468-9126
Practice Address - Country:US
Practice Address - Phone:585-944-6317
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-23
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031072363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant