Provider Demographics
NPI:1780014233
Name:CORNWELL, AMANDA (PA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:CORNWELL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3942 DAVIS STUART RD STE 2
Mailing Address - Street 2:
Mailing Address - City:RONCEVERTE
Mailing Address - State:WV
Mailing Address - Zip Code:24970-0269
Mailing Address - Country:US
Mailing Address - Phone:304-645-7546
Mailing Address - Fax:
Practice Address - Street 1:3942 DAVIS STUART RD STE 2
Practice Address - Street 2:
Practice Address - City:RONCEVERTE
Practice Address - State:WV
Practice Address - Zip Code:24970-0269
Practice Address - Country:US
Practice Address - Phone:304-645-7546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-20
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV667363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant