Provider Demographics
NPI:1659332799
Name:CORNEJO, CRISTOBAL JR (PA-C)
Entity Type:Individual
Prefix:
First Name:CRISTOBAL
Middle Name:
Last Name:CORNEJO
Suffix:JR
Gender:M
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 1:7 TRISTAN CT
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01602-1314
Mailing Address - Country:US
Mailing Address - Phone:774-261-0323
Mailing Address - Fax:
Practice Address - Street 1:360 HUNTINGTON AVE
Practice Address - Street 2:135 FORSYTH BUILDING
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5005
Practice Address - Country:US
Practice Address - Phone:617-373-8933
Practice Address - Fax:617-373-2601
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA653363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAQ18911Medicare UPIN
MAAP2135Medicare ID - Type Unspecified