Provider Demographics
NPI:1801225099
Name:SMITH, CORY R (AA)
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:R
Last Name:SMITH
Suffix:
Gender:M
Credentials:AA
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:820 PRUDENTIAL DR
Mailing Address - Street 2:SUITE 606
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-8210
Mailing Address - Country:US
Mailing Address - Phone:904-398-3356
Mailing Address - Fax:904-398-5397
Practice Address - Street 1:820 PRUDENTIAL DR
Practice Address - Street 2:SUITE 606
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8210
Practice Address - Country:US
Practice Address - Phone:904-398-3356
Practice Address - Fax:904-398-5397
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-07
Last Update Date:2013-11-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLAA193367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant