Healthcare Provider Details

I. General information

NPI: 1932620739
Provider Name (Legal Business Name): COREY SCOTT PICKETT DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2017
Last Update Date: 11/11/2021
Certification Date: 11/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9605 SANDIFUR PKWY
PASCO WA
99301-8028
US

IV. Provider business mailing address

550 GAGE BLVD STE 101
RICHLAND WA
99352-9532
US

V. Phone/Fax

Practice location:
  • Phone: 509-942-3170
  • Fax: 509-543-9795
Mailing address:
  • Phone: 509-942-3627
  • Fax: 509-627-2983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberOP61022938
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number227072
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOP61022938
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: