Provider Demographics
NPI:1255810255
Name:CORNETT, BENJAMIN CHRISTOPHER
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:CHRISTOPHER
Last Name:CORNETT
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 1:5314 RUNNINGBROOK RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89120-1900
Mailing Address - Country:US
Mailing Address - Phone:702-884-3073
Mailing Address - Fax:
Practice Address - Street 1:5314 RUNNINGBROOK RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-1900
Practice Address - Country:US
Practice Address - Phone:702-884-3073
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-09
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV$$$$$$$$$Medicaid