Provider Demographics
NPI:1033771043
Name:CORNEJO GONZALEZ, ANGELICA CAROLINA (MD)
Entity type:Individual
Prefix:DR
First Name:ANGELICA
Middle Name:CAROLINA
Last Name:CORNEJO GONZALEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANGELICA
Other - Middle Name:
Other - Last Name:CORNEJO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1155 MILL ST # M14
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-1576
Mailing Address - Country:US
Mailing Address - Phone:775-982-5262
Mailing Address - Fax:775-982-5496
Practice Address - Street 1:75 PRINGLE WAY STE 401
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-1476
Practice Address - Country:US
Practice Address - Phone:775-982-2970
Practice Address - Fax:775-982-2973
Is Sole Proprietor?:No
Enumeration Date:2019-07-01
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV249092084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV24909OtherNV MD LICENSE
NV16177931OtherCAQH