Provider Demographics
NPI:1518207133
Name:CORNELIUS, NATHAN MICHAEL (DC)
Entity Type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:MICHAEL
Last Name:CORNELIUS
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 1:2421 HANLEY RD
Mailing Address - Street 2:STE 800
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-8400
Mailing Address - Country:US
Mailing Address - Phone:715-386-4075
Mailing Address - Fax:715-386-4069
Practice Address - Street 1:1965 CLIFF LAKE RD STE 103
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-2591
Practice Address - Country:US
Practice Address - Phone:651-340-2609
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-19
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5760111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor