Provider Demographics
NPI:1285251033
Name:AUSTIN, CORY RAY (CRNA, DNP)
Entity type:Individual
Prefix:
First Name:CORY
Middle Name:RAY
Last Name:AUSTIN
Suffix:
Gender:M
Credentials:CRNA, DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 SHERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-2155
Mailing Address - Country:US
Mailing Address - Phone:314-332-7969
Mailing Address - Fax:
Practice Address - Street 1:6800 STATE ROUTE 162
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-8500
Practice Address - Country:US
Practice Address - Phone:618-288-5711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-28
Last Update Date:2020-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209021526367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered