MEDICARE: MR. CORY SHANE HOPPER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant

General Provider Information

NPI Number	:	1255883567
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CORY SHANE HOPPER

Provider Business Mailing Address
First Line	:	805 SMALLWOOD DR
Second Line	:
City	:	JACKSONVILLE
State	:	NC
Zip	:	28540-3836
Country	:	US
Telephone Number	:	325-320-2786
Fax Number	:

Provider Business Practice Location Address
First Line	:	805 SMALLWOOD DR
Second Line	:
City	:	JACKSONVILLE
State	:	NC
Zip	:	28540-3836
Country	:	US
Telephone Number	:	325-320-2786
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/03/2016
Last Update Date	:	03/13/2026

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