Provider Demographics
NPI:1215990122
Name:WIRT, CORY (PT, MS PT, TPI-CGFI)
Entity type:Individual
Prefix:MR
First Name:CORY
Middle Name:
Last Name:WIRT
Suffix:
Gender:M
Credentials:PT, MS PT, TPI-CGFI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:771 PILOT HOUSE DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-1990
Mailing Address - Country:US
Mailing Address - Phone:757-873-2302
Mailing Address - Fax:757-873-2306
Practice Address - Street 1:6049 HARBOUR PARK DRIVE
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112
Practice Address - Country:US
Practice Address - Phone:804-639-2359
Practice Address - Fax:804-639-2029
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305202875225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP00398183OtherRAILROAD MEDICARE
VA192944OtherBCBS PHYSICAL THERAPY
VA010157692Medicaid
3909474OtherAETNA
VA192944OtherBCBS PHYSICAL THERAPY
3909474OtherAETNA