Provider Demographics
NPI:1255168407
Name:THOMAS, CORY LAMONT
Entity type:Individual
Prefix:
First Name:CORY
Middle Name:LAMONT
Last Name:THOMAS
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 1:810 E 61ST ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98404-2313
Mailing Address - Country:US
Mailing Address - Phone:253-882-9281
Mailing Address - Fax:
Practice Address - Street 1:810 E 61ST ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98404-2313
Practice Address - Country:US
Practice Address - Phone:253-882-9281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-19
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver