Provider Demographics
NPI:1558710889
Name:BRISCOE, CORY FRANKLIN
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:FRANKLIN
Last Name:BRISCOE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:CORY
Other - Middle Name:
Other - Last Name:BRISCOE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:APRN CRNA
Mailing Address - Street 1:2254 E MCPHERSON ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-4799
Mailing Address - Country:US
Mailing Address - Phone:208-201-7088
Mailing Address - Fax:
Practice Address - Street 1:338 E BANNOCK ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6207
Practice Address - Country:US
Practice Address - Phone:208-489-6789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-07
Last Update Date:2017-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9367780207L00000X
IDARNP9367780367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology