Provider Demographics
NPI:1578665329
Name:RASMUSSEN, COREY LAYNE (DPT)
Entity Type:Individual
Prefix:DR
First Name:COREY
Middle Name:LAYNE
Last Name:RASMUSSEN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1940 S BONITO WAY STE 190
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-5618
Mailing Address - Country:US
Mailing Address - Phone:208-287-9420
Mailing Address - Fax:
Practice Address - Street 1:675 YELLOWSTONE AVE STE 1
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4511
Practice Address - Country:US
Practice Address - Phone:208-254-7626
Practice Address - Fax:208-232-9168
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDDPT-2070174400000X
IDPT-2070225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1651182Medicare UPIN