Provider Demographics
NPI:1477765501
Name:WADLEY, CORI ELENA (PA)
Entity Type:Individual
Prefix:MRS
First Name:CORI
Middle Name:ELENA
Last Name:WADLEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21700 190TH ST
Mailing Address - Street 2:
Mailing Address - City:PURCELL
Mailing Address - State:OK
Mailing Address - Zip Code:73080
Mailing Address - Country:US
Mailing Address - Phone:405-691-5208
Mailing Address - Fax:405-799-6500
Practice Address - Street 1:11601 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73170
Practice Address - Country:US
Practice Address - Phone:405-691-5208
Practice Address - Fax:405-378-0556
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1519363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant