Provider Demographics
NPI:1568694834
Name:CORNELL, MARK WAYNE (CRNA)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:WAYNE
Last Name:CORNELL
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9703 WIND GATE PARKWAY
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78254-5995
Mailing Address - Country:US
Mailing Address - Phone:210-834-6461
Mailing Address - Fax:
Practice Address - Street 1:1215 E COURT ST
Practice Address - Street 2:
Practice Address - City:SEGUIN
Practice Address - State:TX
Practice Address - Zip Code:78155-5129
Practice Address - Country:US
Practice Address - Phone:830-379-5867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-19
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP125527367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered