Provider Demographics
NPI:1467798231
Name:CORNELIUS, ROXANNE KAY (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:ROXANNE
Middle Name:KAY
Last Name:CORNELIUS
Suffix:
Gender:F
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 1:8849 TAMARISK CIRCLE
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49083
Mailing Address - Country:US
Mailing Address - Phone:269-501-3143
Mailing Address - Fax:
Practice Address - Street 1:555 MIDTOWNE ST NE
Practice Address - Street 2:SUITE 110
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-5729
Practice Address - Country:US
Practice Address - Phone:616-588-8880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-21
Last Update Date:2012-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003078363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical