Healthcare Provider Details

I. General information

NPI: 1205204781
Provider Name (Legal Business Name): CORY MITCHELL WHITLOCK PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2015
Last Update Date: 05/01/2025
Certification Date: 05/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2481 W HORIZON RIDGE PKWY STE 100
HENDERSON NV
89052-5926
US

IV. Provider business mailing address

427 BLACKRIDGE RD
HENDERSON NV
89015-7632
US

V. Phone/Fax

Practice location:
  • Phone: 775-848-6971
  • Fax: 702-680-1377
Mailing address:
  • Phone: 775-848-6971
  • Fax: 702-680-1377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License NumberPA1821
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA1821
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: