Provider Demographics
NPI:1689223414
Name:MORTENSEN, CORY FRASER
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:FRASER
Last Name:MORTENSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8559 CORDIAL RD
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92021-2133
Mailing Address - Country:US
Mailing Address - Phone:619-599-6136
Mailing Address - Fax:
Practice Address - Street 1:8559 CORDIAL RD
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92021-2133
Practice Address - Country:US
Practice Address - Phone:619-599-6136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-04
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider