Provider Demographics
NPI:1295211704
Name:HALLACY, CHARLES CORY
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:CORY
Last Name:HALLACY
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 1:303 S PINE ST
Mailing Address - Street 2:
Mailing Address - City:ARMA
Mailing Address - State:KS
Mailing Address - Zip Code:66712-4008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3066 N KENTUCKY ST
Practice Address - Street 2:
Practice Address - City:IOLA
Practice Address - State:KS
Practice Address - Zip Code:66749-1951
Practice Address - Country:US
Practice Address - Phone:620-365-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-17
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS557616367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty