Provider Demographics
NPI:1134107352
Name:CORNELIUS, SHELLIE (PA)
Entity Type:Individual
Prefix:
First Name:SHELLIE
Middle Name:
Last Name:CORNELIUS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1541 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4615
Mailing Address - Country:US
Mailing Address - Phone:850-431-7805
Mailing Address - Fax:850-431-7809
Practice Address - Street 1:1541 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4615
Practice Address - Country:US
Practice Address - Phone:850-431-7805
Practice Address - Fax:850-431-7809
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110840579363A00000X
FLPA9106607363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S30425Medicare UPIN