Healthcare Provider Details

I. General information

NPI: 1699440958
Provider Name (Legal Business Name): CORY IPSEN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2021
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

782 MEDICAL CENTER DR E STE 311
CLOVIS CA
93611-6892
US

IV. Provider business mailing address

PO BOX 25100
FRESNO CA
93729-5100
US

V. Phone/Fax

Practice location:
  • Phone: 559-472-4600
  • Fax:
Mailing address:
  • Phone: 801-413-9432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: