Provider Demographics
NPI:1689019614
Name:WHITESIDES, COREY MICHAEL (PA-C)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:MICHAEL
Last Name:WHITESIDES
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2790 CLAY EDWARDS DR
Mailing Address - Street 2:STE 600
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64116-3276
Mailing Address - Country:US
Mailing Address - Phone:816-561-3003
Mailing Address - Fax:816-889-1584
Practice Address - Street 1:2790 CLAY EDWARDS DR
Practice Address - Street 2:STE 600
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64116-3276
Practice Address - Country:US
Practice Address - Phone:816-561-3003
Practice Address - Fax:816-889-1584
Is Sole Proprietor?:No
Enumeration Date:2013-05-03
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2013013231363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical