Provider Demographics
NPI:1730105768
Name:CORNN, BRET A (PAC)
Entity type:Individual
Prefix:MR
First Name:BRET
Middle Name:A
Last Name:CORNN
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 W TIPTON ST
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR
Mailing Address - State:IN
Mailing Address - Zip Code:47274-2640
Mailing Address - Country:US
Mailing Address - Phone:812-523-5862
Mailing Address - Fax:812-523-4753
Practice Address - Street 1:411 W TIPTON ST
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:IN
Practice Address - Zip Code:47274
Practice Address - Country:US
Practice Address - Phone:812-523-5862
Practice Address - Fax:812-523-4753
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000310A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S51154Medicare UPIN