Provider Demographics
NPI:1932647112
Name:CALLAHAN, CORY (PA-C)
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:
Last Name:CALLAHAN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 W OAKLAND AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2192
Mailing Address - Country:US
Mailing Address - Phone:423-302-6565
Mailing Address - Fax:
Practice Address - Street 1:410 N STATE OF FRANKLIN RD STE 140
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6972
Practice Address - Country:US
Practice Address - Phone:423-431-2460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-07
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA1675363A00000X
TN5089363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant