Provider Demographics
NPI:1902961626
Name:CORNWELL, SHANNON L (PA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:L
Last Name:CORNWELL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4401 W MEMORIAL RD
Mailing Address - Street 2:SUITE 121
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-1785
Mailing Address - Country:US
Mailing Address - Phone:405-751-4664
Mailing Address - Fax:405-749-4561
Practice Address - Street 1:101 E VALENCIA MESA DR
Practice Address - Street 2:EM DEPT
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-3809
Practice Address - Country:US
Practice Address - Phone:714-992-3965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2009-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17022363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPA17022AMedicaid
CA330311953OtherTRICARE
CA330311953OtherTRICARE
CAWPA17022AMedicaid