Provider Demographics
NPI:1659526044
Name:WASE, CORI M (MSPT)
Entity Type:Individual
Prefix:
First Name:CORI
Middle Name:M
Last Name:WASE
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:CORI
Other - Middle Name:M
Other - Last Name:WASE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSPT
Mailing Address - Street 1:747 MADISON AVE
Mailing Address - Street 2:STE 1
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208-3392
Mailing Address - Country:US
Mailing Address - Phone:518-489-2524
Mailing Address - Fax:518-489-3617
Practice Address - Street 1:747 MADISON AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-3385
Practice Address - Country:US
Practice Address - Phone:518-443-2279
Practice Address - Fax:518-443-7246
Is Sole Proprietor?:No
Enumeration Date:2008-11-26
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030881-1225100000X
NY030881225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist