Provider Demographics
NPI:1245201862
Name:COREY, GWYN (MD)
Entity type:Individual
Prefix:
First Name:GWYN
Middle Name:
Last Name:COREY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 821350
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98682
Mailing Address - Country:US
Mailing Address - Phone:360-687-5221
Mailing Address - Fax:360-666-0466
Practice Address - Street 1:3400 MAIN ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98663
Practice Address - Country:US
Practice Address - Phone:360-696-5016
Practice Address - Fax:360-696-5032
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD230512084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8373979Medicaid
WA8373979Medicaid
H83910Medicare UPIN