Provider Demographics
NPI:1255883567
Name:HOPPER, CORY SHANE
Entity type:Individual
Prefix:MR
First Name:CORY
Middle Name:SHANE
Last Name:HOPPER
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 1:34101 FARENHOLT AVE
Mailing Address - Street 2:BLDG 14
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92134-5291
Mailing Address - Country:US
Mailing Address - Phone:619-532-9712
Mailing Address - Fax:
Practice Address - Street 1:34101 FARENHOLT AVE
Practice Address - Street 2:BLDG 14
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-5291
Practice Address - Country:US
Practice Address - Phone:619-532-9712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-03
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman