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General NPI Number Information
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NPI Number | 1235490038
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Entity Type | Individual
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Provider Name | BLAKE COOPER CORCORAN M.D.
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Gender | Male
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Dates
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Enumeration Date | 06/07/2012
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Last Update Date | 12/20/2024
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Provider Practice Location Address
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Address Line | 675 N 5TH ST
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City | LEBANON
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State | OR
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Zip | 97355-2875
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Country | US
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Telephone | 541-451-6282
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1189
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City | CORVALLIS
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State | OR
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Zip | 97339-1189
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QS0010X
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Taxonomy Name | Sports Medicine (Family Medicine) Physician
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License Number | MD60771757
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 207QS0010X
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Taxonomy Name | Sports Medicine (Family Medicine) Physician
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License Number | MD222671
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License Number State | OR
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Taxonomy #3
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | MD458625
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License Number State | PA
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Taxonomy #4
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | MD600771757
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License Number State | WA
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Taxonomy #5
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Taxonomy Code | 207QS0010X
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Taxonomy Name | Sports Medicine (Family Medicine) Physician
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License Number | MD458625
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License Number State | PA
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