Provider Demographics
NPI:1134986003
Name:CORNELL, KRISTIN (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:CORNELL
Suffix:
Gender:F
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 1:218 PARK DR
Mailing Address - Street 2:
Mailing Address - City:DOWNINGTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19335-2118
Mailing Address - Country:US
Mailing Address - Phone:610-806-2356
Mailing Address - Fax:
Practice Address - Street 1:4755 OGLETOWN STANTON RD STE 2670
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19718-5544
Practice Address - Country:US
Practice Address - Phone:302-733-2438
Practice Address - Fax:302-733-4832
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-06
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0073462255A2300X
DEC5-0012078363AS0400X
MDC0009422363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty