Provider Demographics
NPI:1629201249
Name:MARTIN, CORY M (PA-C)
Entity Type:Individual
Prefix:MR
First Name:CORY
Middle Name:M
Last Name:MARTIN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-367-8550
Mailing Address - Fax:208-367-8555
Practice Address - Street 1:3025 W CHERRY LANE
Practice Address - Street 2:STE B
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642
Practice Address - Country:US
Practice Address - Phone:208-367-8550
Practice Address - Fax:208-367-8555
Is Sole Proprietor?:No
Enumeration Date:2009-08-30
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001138A363A00000X
IDPA-1177363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM400044676Medicare PIN
INP01180689Medicare PIN