Provider Demographics
NPI:1588998371
Name:ANDERSON, CORY DALE (PA-C)
Entity type:Individual
Prefix:MR
First Name:CORY
Middle Name:DALE
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1690 US HIGHWAY 1 S STE 100
Mailing Address - Street 2:
Mailing Address - City:SOUTHERN PINES
Mailing Address - State:NC
Mailing Address - Zip Code:28387-7037
Mailing Address - Country:US
Mailing Address - Phone:910-692-7449
Mailing Address - Fax:
Practice Address - Street 1:1690 US HIGHWAY 1 S STE 100
Practice Address - Street 2:
Practice Address - City:SOUTHERN PINES
Practice Address - State:NC
Practice Address - Zip Code:28387-7037
Practice Address - Country:US
Practice Address - Phone:910-692-7449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-25
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2667363A00000X
NC0010-08057363A00000X
KS1501523363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant