Provider Demographics
NPI:1639426752
Name:CORNETT, CAROL ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:ANN
Last Name:CORNETT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:ANN
Other - Last Name:JAMES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:8612 OLIVE BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63132-2504
Mailing Address - Country:US
Mailing Address - Phone:314-692-8055
Mailing Address - Fax:314-692-5513
Practice Address - Street 1:8612 OLIVE BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63132-2504
Practice Address - Country:US
Practice Address - Phone:314-692-8055
Practice Address - Fax:314-692-5513
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-08
Last Update Date:2017-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9106633363AM0700X
MO2017029444363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA 9106633OtherSTATE OF FLORIDA LICENSE
MO2017029444OtherSTATE OF MISSOURI LICENSE