Provider Demographics
NPI:1164479218
Name:CORNELIUS, WENDY W (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:WENDY
Middle Name:W
Last Name:CORNELIUS
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 1:2871 ACTON ROAD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35243-2560
Mailing Address - Country:US
Mailing Address - Phone:205-939-0023
Mailing Address - Fax:205-939-4180
Practice Address - Street 1:2871 ACTON ROAD
Practice Address - Street 2:SUITE 100
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35243-2560
Practice Address - Country:US
Practice Address - Phone:205-939-0023
Practice Address - Fax:205-939-4180
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2011-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA-325363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL891004890Medicaid
AL051514938OtherBLUE CROSS - 860 MONT RD
AL051512489OtherBLUE CROSS - 48 MED PARK
AL009932896Medicaid
AL051514195OtherBLUE CROSS - 2660 10TH AV
AL009955735Medicaid
AL051512489Medicare PIN
AL051514195OtherBLUE CROSS - 2660 10TH AV