Provider Demographics
NPI:1659464865
Name:CORY, KRISTY H (PAC)
Entity Type:Individual
Prefix:MRS
First Name:KRISTY
Middle Name:H
Last Name:CORY
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2551 GREENWOOD ROAD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-3905
Mailing Address - Country:US
Mailing Address - Phone:318-635-0834
Mailing Address - Fax:318-636-2331
Practice Address - Street 1:2551 GREENWOOD ROAD
Practice Address - Street 2:SUITE 210
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-3905
Practice Address - Country:US
Practice Address - Phone:318-635-0834
Practice Address - Fax:318-636-2331
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPAA10364363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5J167P228Medicare ID - Type Unspecified