Provider Demographics
NPI:1205204781
Name:WHITLOCK, CORY MITCHELL (PAC)
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:MITCHELL
Last Name:WHITLOCK
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 1:427 BLACKRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89015-7632
Mailing Address - Country:US
Mailing Address - Phone:775-848-6971
Mailing Address - Fax:702-680-1377
Practice Address - Street 1:2481 W HORIZON RIDGE PKWY STE 100
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-5926
Practice Address - Country:US
Practice Address - Phone:775-848-6971
Practice Address - Fax:702-680-1377
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-14
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NVPA18212083P0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program