Provider Demographics
NPI:1093068595
Name:CORNELISON, JARED B (PA-C)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:B
Last Name:CORNELISON
Suffix:
Gender:M
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 1:431 N 15TH AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4058
Mailing Address - Country:US
Mailing Address - Phone:208-339-5726
Mailing Address - Fax:
Practice Address - Street 1:3901 CAPITAL MALL DR SW
Practice Address - Street 2:STE A
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-1178
Practice Address - Country:US
Practice Address - Phone:360-786-8990
Practice Address - Fax:360-786-9010
Is Sole Proprietor?:No
Enumeration Date:2012-10-22
Last Update Date:2013-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60360929363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant