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General NPI Number Information
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NPI Number | 1811403363
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Entity Type | Individual
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Provider Name | CHRISTINE E CORK PA-C CAQ PSYCH
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Gender | Female
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Dates
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Enumeration Date | 12/20/2017
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Last Update Date | 02/15/2024
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Provider Practice Location Address
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Address Line | 635 GOOSEBERRY DR UNIT 1905
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City | LONGMONT
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State | CO
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Zip | 80503-6457
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Country | US
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Telephone | 678-697-9665
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Fax |
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Provider Business Mailing Address
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Address Line | 635 GOOSEBERRY DR UNIT 1905
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City | LONGMONT
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State | CO
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Zip | 80503-6457
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Country | US
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Telephone | 678-697-9665
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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 | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | PA.0005295
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License Number State | CO
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA.0005295
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License Number State | CO
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