Provider Demographics
NPI:1144395708
Name:PETERS, CORY GRANT (PA)
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:GRANT
Last Name:PETERS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
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Other - Last Name:
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Mailing Address - Street 1:6800 SOUTHPOINT PKWY STE 300
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-8203
Mailing Address - Country:US
Mailing Address - Phone:904-634-0640
Mailing Address - Fax:904-634-0203
Practice Address - Street 1:10475 CENTURION PKWY N
Practice Address - Street 2:SUITE 220
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256
Practice Address - Country:US
Practice Address - Phone:904-634-0640
Practice Address - Fax:904-634-0203
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC4662255A2300X
FLPA9106781363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9106781OtherLICENSE