Provider Demographics
NPI:1609954015
Name:CORLESS, H GARY (DPM)
Entity Type:Individual
Prefix:
First Name:H
Middle Name:GARY
Last Name:CORLESS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11009
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98508-1009
Mailing Address - Country:US
Mailing Address - Phone:425-775-6996
Mailing Address - Fax:425-670-8905
Practice Address - Street 1:7315 212TH ST SW
Practice Address - Street 2:#103
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026
Practice Address - Country:US
Practice Address - Phone:425-775-6996
Practice Address - Fax:425-670-8905
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPO00000139213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9050600OtherMEDICAID/DMERC
WA1183409Medicaid
0164994OtherL AND I
WA5182COOtherREGENCE RIDER
WA9050600OtherMEDICAID/DMERC
U26549Medicare UPIN
0164994OtherL AND I