Provider Demographics
NPI:1942051305
Name:MIRISE, CORDIN
Entity Type:Individual
Prefix:
First Name:CORDIN
Middle Name:
Last Name:MIRISE
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 1:3325 W 100 N
Mailing Address - Street 2:
Mailing Address - City:BARGERSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46106-9582
Mailing Address - Country:US
Mailing Address - Phone:317-670-7079
Mailing Address - Fax:
Practice Address - Street 1:7750 W 200 S
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:IN
Practice Address - Zip Code:46571-9436
Practice Address - Country:US
Practice Address - Phone:260-768-7918
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-01
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program