Provider Demographics
NPI:1235490038
Name:CORCORAN, BLAKE COOPER (MD)
Entity Type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:COOPER
Last Name:CORCORAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 SE WASHINGTON ST.
Mailing Address - Street 2:
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99164
Mailing Address - Country:US
Mailing Address - Phone:509-335-3575
Mailing Address - Fax:509-335-6223
Practice Address - Street 1:1125 SE WASHINGTON ST.
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99164
Practice Address - Country:US
Practice Address - Phone:509-335-3575
Practice Address - Fax:509-335-6223
Is Sole Proprietor?:No
Enumeration Date:2012-06-07
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD458625207Q00000X, 207QS0010X
WAMD600771757207Q00000X
WAMD60771757207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine