Provider Demographics
NPI:1508270992
Name:WOOD, COREY
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:
Last Name:WOOD
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 1:1665 S RADISSON DR APT 206
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72701-5549
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1255 S. RAZORBACK RD.
Practice Address - Street 2:BAUM STADIUM
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72701
Practice Address - Country:US
Practice Address - Phone:479-935-7245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-13
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAT 523390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program