Provider Demographics
NPI:1518925106
Name:CORNWALL, SUZANNE JOLEEN GIBSON (MD)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:JOLEEN GIBSON
Last Name:CORNWALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUZANNE
Other - Middle Name:J
Other - Last Name:CORNWALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:450 S KITSAP BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-3738
Mailing Address - Country:US
Mailing Address - Phone:360-895-8900
Mailing Address - Fax:360-895-8999
Practice Address - Street 1:450 S KITSAP BLVD STE 210
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-3738
Practice Address - Country:US
Practice Address - Phone:360-895-8900
Practice Address - Fax:360-895-8999
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60170321207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47078557509Medicaid
WA2009011Medicaid
NEG22936Medicare UPIN