Provider Demographics
NPI:1164586400
Name:CORDER, FRED JR (PA-C)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:
Last Name:CORDER
Suffix:JR
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 1:946 SEVERN DR
Mailing Address - Street 2:
Mailing Address - City:COSHOCTON
Mailing Address - State:OH
Mailing Address - Zip Code:43812-2737
Mailing Address - Country:US
Mailing Address - Phone:740-622-4916
Mailing Address - Fax:
Practice Address - Street 1:440 BROWNS LN
Practice Address - Street 2:
Practice Address - City:COSHOCTON
Practice Address - State:OH
Practice Address - Zip Code:43812-2044
Practice Address - Country:US
Practice Address - Phone:740-622-0332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.000341363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH50.000341OtherPA-C LICENSE NUMBER