Provider Demographics
NPI:1710104062
Name:VALLANCE, CORY ALLISON (PA-C)
Entity Type:Individual
Prefix:MS
First Name:CORY
Middle Name:ALLISON
Last Name:VALLANCE
Suffix:
Gender:F
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 1:2970 HAVASUPAI AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-1641
Mailing Address - Country:US
Mailing Address - Phone:858-412-6161
Mailing Address - Fax:
Practice Address - Street 1:1075 CAMINO DEL RIO S
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3538
Practice Address - Country:US
Practice Address - Phone:619-881-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19137363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant