Provider Demographics
NPI:1972992295
Name:CORNTASSEL, CODY ROBERT (ATC, LAT)
Entity type:Individual
Prefix:MR
First Name:CODY
Middle Name:ROBERT
Last Name:CORNTASSEL
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 OWEN LN APT 713
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-8910
Mailing Address - Country:US
Mailing Address - Phone:918-961-1527
Mailing Address - Fax:
Practice Address - Street 1:415 OWEN LN APT 713
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-8910
Practice Address - Country:US
Practice Address - Phone:918-961-1527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-12
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT56532255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer