Healthcare Provider Details

I. General information

NPI: 1528857372
Provider Name (Legal Business Name): COREY MARK PENDERGRAFT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2025
Last Update Date: 02/02/2026
Certification Date: 02/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

WSU FAMILY MEDICINE RESIDENCY CENTER 825 SE BISHOP BLVD STE 401
PULLMAN WA
99163
US

IV. Provider business mailing address

825 SE BISHOP BLVD STE 401
PULLMAN WA
99163-5517
US

V. Phone/Fax

Practice location:
  • Phone: 509-336-7720
  • Fax:
Mailing address:
  • Phone: 509-336-7720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberML61690777
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: