Provider Demographics
NPI:1508313396
Name:PREWITT, CORY (CRNA)
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:
Last Name:PREWITT
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6225 N STATE HIGHWAY 161 STE 200
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-2241
Mailing Address - Country:US
Mailing Address - Phone:214-687-0001
Mailing Address - Fax:
Practice Address - Street 1:1201 PLEASANT VALLEY RD
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-9811
Practice Address - Country:US
Practice Address - Phone:270-417-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-08
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN0000180432163W00000X
KY3010698367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse