Basic Information
| Provider Information | |||||||||
| NPI: | 1346484912 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HERRICK | ||||||||
| FirstName: | KORY | ||||||||
| MiddleName: | SCOTT | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 25608 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841250608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063204476 | ||||||||
| FaxNumber: | 2065687043 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 17TH AVE | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981225711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063202800 | ||||||||
| FaxNumber: | 2063202827 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2009 | ||||||||
| LastUpdateDate: | 03/09/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2084N0400X | MD163630 | OR | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | MD60650418 | WA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No ID Information.