Provider Demographics
NPI:1710680335
Name:CORNEJO, MARIO JAMIE
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:JAMIE
Last Name:CORNEJO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 W ABRIENDO AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-1003
Mailing Address - Country:US
Mailing Address - Phone:719-543-1173
Mailing Address - Fax:719-543-6325
Practice Address - Street 1:1201 W ABRIENDO AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-1003
Practice Address - Country:US
Practice Address - Phone:719-543-1173
Practice Address - Fax:719-543-6325
Is Sole Proprietor?:No
Enumeration Date:2023-03-23
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTA.0012995225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant