KROUSE, CORA E (PA-C)

Provider Demographics

• NPI: 1891768560
• Name: KROUSE, CORA E (PA-C)
• Entity Type: Individual
• First Name: CORA
• Middle Name: E
• Last Name: KROUSE
• Gender: F
• Credentials: PA-C
• Other - First Name: CORA
• Other - Middle Name: E
• Other - Last Name: CUMMINS
• Other - Last Name Type: Former Name
• Mailing Address - Street 1: 1717 S J ST
• Mailing Address - City: TACOMA
• Mailing Address - State: WA
• Mailing Address - Zip Code: 98405-4933
• Mailing Address - Country: US
• Mailing Address - Phone: 253-426-6341
• Mailing Address - Fax: 253-426-6344
• Practice Address - Street 1: 1717 S J ST
• Practice Address - City: TACOMA
• Practice Address - State: WA
• Practice Address - Zip Code: 98405-4933
• Practice Address - Country: US
• Practice Address - Phone: 253-426-6341
• Practice Address - Fax: 253-426-6344
• Is Sole Proprietor?: No
• Enumeration Date: 2006-02-10
• Last Update Date: 2020-12-07

Provider Licenses

State	License ID	Taxonomies
WA	PA10003891	363AM0700X, 363A00000X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization
Yes	363A00000X	Physician Assistants & Advanced Practice Nursing Providers	Physician Assistant
No	363AM0700X	Physician Assistants & Advanced Practice Nursing Providers	Physician Assistant	Medical

Provider Identifiers

State	Identifier ID	ID Type	Issuer
WA	8327124	Medicaid
WA	0238873	Other	STATE L&I
WA	0273766	Other	STATE L&I
WA	1021533	Medicaid
WA	0302690	Other	STATE L&I
WA	PA10003891	Other	WA LICENSE
WA	G8875113	Medicare PIN
WA	000188100	Medicare PIN
WA	G8851595	Medicare PIN
WA	G8851596	Medicare PIN
WA	G8851597	Medicare PIN
WA	AB13749	Medicare PIN
WA	0302690	Other	STATE L&I
WA	G8851594	Medicare PIN
WA	G8875112	Medicare PIN
WA	AB13750	Medicare PIN
WA	970012950	Medicare PIN
WA	PA10003891	Other	WA LICENSE
WA	0238873	Other	STATE L&I