Provider Demographics
NPI:1184984528
Name:BROWN, CORY BRANDON (MS, ATC, LAT)
Entity type:Individual
Prefix:
First Name:CORY
Middle Name:BRANDON
Last Name:BROWN
Suffix:
Gender:M
Credentials:MS, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1295 GAINESWAY DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40517-2816
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3401 YORKSHIRE MEDICAL PARK
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-2513
Practice Address - Country:US
Practice Address - Phone:859-263-5140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-19
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0033042255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
1021710OtherNATA
2000001929OtherBOC ATC
IL096.003304OtherIL STATE LICENSE