Healthcare Provider Details

I. General information

NPI: 1891408399
Provider Name (Legal Business Name): COREY T KOCISKO CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2022
Last Update Date: 12/29/2022
Certification Date: 12/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER BLVD
COOKEVILLE TN
38501-4294
US

IV. Provider business mailing address

7312 MARTINGALE DR
POWELL TN
37849-5159
US

V. Phone/Fax

Practice location:
  • Phone: 931-528-2541
  • Fax:
Mailing address:
  • Phone: 731-307-0360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number143807
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: