Provider Demographics
NPI:1356852164
Name:CORNWALL, TIMOTHY NEAL
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:NEAL
Last Name:CORNWALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8408 E FLEMING RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:WA
Mailing Address - Zip Code:99012-9710
Mailing Address - Country:US
Mailing Address - Phone:509-723-5188
Mailing Address - Fax:
Practice Address - Street 1:800 W 5TH AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204
Practice Address - Country:US
Practice Address - Phone:509-473-7626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-19
Last Update Date:2018-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00168846163WP0000X
WAAP60807265367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WP0000XNursing Service ProvidersRegistered NursePain Management