Provider Demographics
NPI:1235599234
Name:THACKER, COREY
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:
Last Name:THACKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1912 NW CIRCLE DR N
Mailing Address - Street 2:
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370-9527
Mailing Address - Country:US
Mailing Address - Phone:407-325-9229
Mailing Address - Fax:
Practice Address - Street 1:1912 NW CIRCLE DR N
Practice Address - Street 2:
Practice Address - City:POULSBO
Practice Address - State:WA
Practice Address - Zip Code:98370-9527
Practice Address - Country:US
Practice Address - Phone:407-325-9229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-03
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman