Provider Demographics
NPI:1164649067
Name:CORNELIUS, CASEY RYAN (DO)
Entity Type:Individual
Prefix:DR
First Name:CASEY
Middle Name:RYAN
Last Name:CORNELIUS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 NE 87TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-1913
Mailing Address - Country:US
Mailing Address - Phone:360-882-2778
Mailing Address - Fax:360-604-1697
Practice Address - Street 1:2525 NE 139TH ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-2719
Practice Address - Country:US
Practice Address - Phone:360-882-2778
Practice Address - Fax:360-604-1697
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2010-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP60094538207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8548281Medicaid
WAG8882304Medicare PIN