Provider Demographics
NPI:1831353051
Name:CORNELIUS, RANDY DEAN (CRNA)
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:DEAN
Last Name:CORNELIUS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:IA
Mailing Address - Zip Code:52057-1526
Mailing Address - Country:US
Mailing Address - Phone:563-927-7356
Mailing Address - Fax:
Practice Address - Street 1:709 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:IA
Practice Address - Zip Code:52057-1526
Practice Address - Country:US
Practice Address - Phone:563-927-7356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-16
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA107246390200000X
IAD107246367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI09230221Medicare PIN
IAP00734624Medicare PIN