Provider Demographics
NPI:1780643197
Name:CORNWALL, RICHARD (PA C)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:CORNWALL
Suffix:
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 1:235 SHALLOWBROOK DR
Mailing Address - Street 2:
Mailing Address - City:ADVANCE
Mailing Address - State:NC
Mailing Address - Zip Code:27006-6732
Mailing Address - Country:US
Mailing Address - Phone:336-816-6800
Mailing Address - Fax:336-940-6545
Practice Address - Street 1:235 SHALLOWBROOK DR
Practice Address - Street 2:
Practice Address - City:ADVANCE
Practice Address - State:NC
Practice Address - Zip Code:27006
Practice Address - Country:US
Practice Address - Phone:336-816-6800
Practice Address - Fax:336-816-6800
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2011-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC100031207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine