Provider Demographics
NPI:1851372643
Name:COREY, MARK (FNP)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:COREY
Suffix:
Gender:M
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 186
Mailing Address - Street 2:
Mailing Address - City:MORO
Mailing Address - State:OR
Mailing Address - Zip Code:97039-0186
Mailing Address - Country:US
Mailing Address - Phone:541-565-3325
Mailing Address - Fax:541-565-3617
Practice Address - Street 1:110 MAIN ST
Practice Address - Street 2:
Practice Address - City:MORO
Practice Address - State:OR
Practice Address - Zip Code:97039-3080
Practice Address - Country:US
Practice Address - Phone:541-565-3325
Practice Address - Fax:541-565-3617
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR093007080N1363LC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR023015Medicaid
OR023015Medicaid