Basic Information
| Provider Information | |||||||||
| NPI: | 1992798896 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CORNYN | ||||||||
| FirstName: | TROY | ||||||||
| MiddleName: | C.N. | ||||||||
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| Credential: | LMP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 731269 | ||||||||
| Address2: | |||||||||
| City: | PUYALLUP | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983730060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538402313 | ||||||||
| FaxNumber: | 2538406340 | ||||||||
| Practice Location | |||||||||
| Address1: | 4703 PACIFIC HWY E | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984242620 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539268202 | ||||||||
| FaxNumber: | 2539268212 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | MA00017360 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |
ID Information
| ID | Type | State | Issuer | Description | 170740 | 01 | WA | DEPT OF L&I | OTHER | 8934971 | 01 | WA | CRIME VICTIMS | OTHER | 4325CO | 01 | WA | REGENCE B/S | OTHER |