Provider Demographics
NPI:1811403363
Name:CORK, CHRISTINE E (PA-C CAQ PSYCH)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:E
Last Name:CORK
Suffix:
Gender:F
Credentials:PA-C CAQ PSYCH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 GOOSEBERRY DR UNIT 1905
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80503-6457
Mailing Address - Country:US
Mailing Address - Phone:678-697-9665
Mailing Address - Fax:
Practice Address - Street 1:635 GOOSEBERRY DR UNIT 1905
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80503-6457
Practice Address - Country:US
Practice Address - Phone:678-697-9665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-20
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.00052952084P0800X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry