Provider Demographics
NPI:1093706558
Name:HALL, CORY T (PAC)
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:T
Last Name:HALL
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 529
Mailing Address - Street 2:
Mailing Address - City:ZEPHYR COVE
Mailing Address - State:NV
Mailing Address - Zip Code:89448-0529
Mailing Address - Country:US
Mailing Address - Phone:775-588-8938
Mailing Address - Fax:775-588-8930
Practice Address - Street 1:1139 3RD ST
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-3465
Practice Address - Country:US
Practice Address - Phone:530-541-3100
Practice Address - Fax:530-541-3016
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15806363A00000X
NVPA678363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVCC1490OtherBCBS
CA0PA158060Medicare PIN
S96096Medicare UPIN
NVV34734Medicare PIN