Provider Demographics
NPI:1225636103
Name:CORNEJO NAVARRO, DANIEL MARTIN (SA-C)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:MARTIN
Last Name:CORNEJO NAVARRO
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25157 RESACA SANTA DR
Mailing Address - Street 2:
Mailing Address - City:SAN BENITO
Mailing Address - State:TX
Mailing Address - Zip Code:78586-8889
Mailing Address - Country:US
Mailing Address - Phone:956-281-8602
Mailing Address - Fax:
Practice Address - Street 1:25157 RESACA SANTA DR
Practice Address - Street 2:
Practice Address - City:SAN BENITO
Practice Address - State:TX
Practice Address - Zip Code:78586-8889
Practice Address - Country:US
Practice Address - Phone:956-281-8602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-13
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20-365246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant