Provider Demographics
NPI:1184609331
Name:CORNELIUS, PENNY S (PA)
Entity type:Individual
Prefix:
First Name:PENNY
Middle Name:S
Last Name:CORNELIUS
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 1:2618 FORESTVILLE DR
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-1358
Mailing Address - Country:US
Mailing Address - Phone:920-496-1631
Mailing Address - Fax:
Practice Address - Street 1:2618 FORESTVILLE DR
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-1358
Practice Address - Country:US
Practice Address - Phone:920-496-1631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI696-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S37085Medicare UPIN