Healthcare Provider Details

I. General information

NPI: 1033145578
Provider Name (Legal Business Name): CORY ADEN-WANSBURY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 08/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6151 DARK HOLLOW RD
MEDFORD OR
97501-4866
US

IV. Provider business mailing address

6151 DARK HOLLOW RD
MEDFORD OR
97501-4866
US

V. Phone/Fax

Practice location:
  • Phone: 541-512-8814
  • Fax:
Mailing address:
  • Phone: 541-512-8814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YX0602X
TaxonomyOtolaryngic Allergy Physician
License NumberG22730
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberMD23944
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code261QP2400X
TaxonomyPrison Health Clinic/Center
License NumberMD23944
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: