Provider Demographics
NPI:1033187265
Name:CORNEILLIE, AMBER (PA-C)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:CORNEILLIE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7070 E DR N
Mailing Address - Street 2:
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49014-8562
Mailing Address - Country:US
Mailing Address - Phone:269-660-1670
Mailing Address - Fax:269-660-0666
Practice Address - Street 1:7070 E DR N
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49014-8562
Practice Address - Country:US
Practice Address - Phone:269-660-1670
Practice Address - Fax:269-660-0666
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601004362363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q36156Medicare UPIN
MIM97310012Medicare PIN