Provider Demographics
NPI:1902190812
Name:HALE, CORY MATTHEW
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:MATTHEW
Last Name:HALE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 SUNBURST LN
Mailing Address - Street 2:
Mailing Address - City:ALLEGANY
Mailing Address - State:NY
Mailing Address - Zip Code:14706-9695
Mailing Address - Country:US
Mailing Address - Phone:716-307-9916
Mailing Address - Fax:
Practice Address - Street 1:5 SUNBURST LN
Practice Address - Street 2:
Practice Address - City:ALLEGANY
Practice Address - State:NY
Practice Address - Zip Code:14706-9695
Practice Address - Country:US
Practice Address - Phone:716-307-9916
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-08
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY088570390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program