Provider Demographics
NPI:1326065913
Name:CORNELL, CLINTON (PA-C)
Entity Type:Individual
Prefix:
First Name:CLINTON
Middle Name:
Last Name:CORNELL
Suffix:
Gender:M
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 1:8595 BEECHMONT AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45255-4740
Mailing Address - Country:US
Mailing Address - Phone:513-713-0177
Mailing Address - Fax:
Practice Address - Street 1:8595 BEECHMONT AVE STE 200
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45255
Practice Address - Country:US
Practice Address - Phone:513-713-0177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003457363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MION85680Medicare PIN