Provider Demographics
NPI:1659431070
Name:KORNISH, GLORIA III
Entity Type:Individual
Prefix:MS
First Name:GLORIA
Middle Name:
Last Name:KORNISH
Suffix:III
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 W SPRUCE ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-4057
Mailing Address - Country:US
Mailing Address - Phone:406-329-2647
Mailing Address - Fax:406-329-5606
Practice Address - Street 1:601 W SPRUCE ST
Practice Address - Street 2:SUITE C
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4057
Practice Address - Country:US
Practice Address - Phone:406-329-2647
Practice Address - Fax:406-329-5606
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT168363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT559637Medicare UPIN