Provider Demographics
NPI:1376845370
Name:HAMMOND, CORY T (PA)
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:T
Last Name:HAMMOND
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 COLUMBUS ST
Mailing Address - Street 2:
Mailing Address - City:HICKSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43526-1250
Mailing Address - Country:US
Mailing Address - Phone:419-542-6692
Mailing Address - Fax:
Practice Address - Street 1:208 COLUMBUS ST
Practice Address - Street 2:
Practice Address - City:HICKSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43526
Practice Address - Country:US
Practice Address - Phone:419-542-6692
Practice Address - Fax:419-542-5667
Is Sole Proprietor?:No
Enumeration Date:2010-11-23
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.004015RX363AS0400X
IN10001240A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000690186OtherANTHEM
OH0203880Medicaid
000000690186OtherANTHEM
INOPRMedicaid