Provider Demographics
NPI:1376366310
Name:CORNELISON, ANDREW DAVID (PA-C)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:DAVID
Last Name:CORNELISON
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Gender:M
Credentials:PA-C
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Mailing Address - Street 1:11050 MT. BELVEDERE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13602-5004
Mailing Address - Country:US
Mailing Address - Phone:515-829-7710
Mailing Address - Fax:
Practice Address - Street 1:11050 MT. BELVEDERE BLVD
Practice Address - Street 2:
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602-5004
Practice Address - Country:US
Practice Address - Phone:515-829-7710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-07
Last Update Date:2024-11-07
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant