Basic Information
| Provider Information | |||||||||
| NPI: | 1639334279 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | DUPONT | ||||||||
| FirstName: | COREY | ||||||||
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| Credential: | P.T | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16083 SW UPPER BOONES FERRY RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | TIGARD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972247736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002198835 | ||||||||
| FaxNumber: | 5034436156 | ||||||||
| Practice Location | |||||||||
| Address1: | 2635 CALDWELL BLVD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | NAMPA | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836516407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084420577 | ||||||||
| FaxNumber: | 2084427455 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2008 | ||||||||
| LastUpdateDate: | 05/19/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT-2398 | ID | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 6101 | OR | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 808487601 | 05 | ID | MEDICAID | 0330316 | 01 | ID | WA L&I | OTHER | 1639334279-000 | 05 | ID | MEDICAID | P01610741 | 01 | ID | RR MEDICARE | OTHER |