Healthcare Provider Details

I. General information

NPI: 1871351866
Provider Name (Legal Business Name): CORY LEE HASTON FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: CORY HUDGINS

II. Dates (important events)

Enumeration Date: 03/13/2024
Last Update Date: 03/13/2024
Certification Date: 03/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 GRANT ST
GARY IN
46402-6099
US

IV. Provider business mailing address

600 GRANT ST
GARY IN
46402-6099
US

V. Phone/Fax

Practice location:
  • Phone: 219-886-4000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71015021A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: