Provider Demographics
NPI:1699440958
Name:IPSEN, CORY (PA-C)
Entity type:Individual
Prefix:
First Name:CORY
Middle Name:
Last Name:IPSEN
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 1:109 E SWIFT AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93704-3512
Mailing Address - Country:US
Mailing Address - Phone:801-413-9432
Mailing Address - Fax:
Practice Address - Street 1:782 MEDICAL CENTER DR E STE 311
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93611-6892
Practice Address - Country:US
Practice Address - Phone:559-472-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-10
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant