Provider Demographics
NPI:1790767333
Name:CORCORAN-SMITH, TONI L (FNP)
Entity Type:Individual
Prefix:
First Name:TONI
Middle Name:L
Last Name:CORCORAN-SMITH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1520
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-3388
Mailing Address - Country:US
Mailing Address - Phone:541-296-5256
Mailing Address - Fax:541-296-5451
Practice Address - Street 1:551 LONE PINE BLVD
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-1520
Practice Address - Country:US
Practice Address - Phone:541-296-5256
Practice Address - Fax:541-296-5451
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200350101NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR218103Medicaid
OR297450Medicaid
OR218103Medicaid
OR297450Medicaid
OR383994Medicare Oscar/Certification
OR118909Medicare ID - Type Unspecified
Q14033Medicare UPIN