Provider Demographics
NPI:1710422951
Name:CORNWELL, MARTHA MADHU (PA-C)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:MADHU
Last Name:CORNWELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MADHU
Other - Middle Name:MARTHA CORNWELL
Other - Last Name:KHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:357 SHIELDS DR
Mailing Address - Street 2:
Mailing Address - City:BENNINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05201-9810
Mailing Address - Country:US
Mailing Address - Phone:802-447-1409
Mailing Address - Fax:802-442-5199
Practice Address - Street 1:357 SHIELDS DR
Practice Address - Street 2:
Practice Address - City:BENNINGTON
Practice Address - State:VT
Practice Address - Zip Code:05201-9810
Practice Address - Country:US
Practice Address - Phone:802-447-1409
Practice Address - Fax:802-442-5199
Is Sole Proprietor?:No
Enumeration Date:2016-12-26
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT055.0031326363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant