Healthcare Provider Details

I. General information

NPI: 1366087330
Provider Name (Legal Business Name): COREY RYAN FROST DEGAIA DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2019
Last Update Date: 10/13/2020
Certification Date: 10/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 OLIVE CHAPEL RD STE 103
APEX NC
27502-8587
US

IV. Provider business mailing address

350 NEW FIDELITY CT
GARNER NC
27529-2665
US

V. Phone/Fax

Practice location:
  • Phone: 919-373-5353
  • Fax:
Mailing address:
  • Phone: 919-258-2714
  • Fax: 410-648-4878

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number61005829
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberP19924
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: