Provider Demographics
NPI:1275387235
Name:CORNELIUSEN, ZACK TYLER (DC)
Entity Type:Individual
Prefix:
First Name:ZACK
Middle Name:TYLER
Last Name:CORNELIUSEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2037 BOYLSTON AVE E APT 21
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98102-3564
Mailing Address - Country:US
Mailing Address - Phone:406-939-4510
Mailing Address - Fax:
Practice Address - Street 1:7010 WOODLAWN AVE NE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98115-5433
Practice Address - Country:US
Practice Address - Phone:206-517-5433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-16
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7191111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor