Provider Demographics
NPI:1790407534
Name:KORNIECK, THOMAS
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:KORNIECK
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:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:800-994-0371
Mailing Address - Fax:
Practice Address - Street 1:2401 S 31ST ST
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76508-1707
Practice Address - Country:US
Practice Address - Phone:254-724-2111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-19
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXPA17150363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program