Healthcare Provider Details

I. General information

NPI: 1447121108
Provider Name (Legal Business Name): CORY LAWLESS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2025
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 LT MICHAEL CLEARY DR
DALLAS PA
18612-1649
US

IV. Provider business mailing address

100 N ACADEMY AVE
DANVILLE PA
17822-4903
US

V. Phone/Fax

Practice location:
  • Phone: 570-675-2000
  • Fax: 570-675-1806
Mailing address:
  • Phone: 570-675-2000
  • Fax: 570-675-1806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA067142
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: