Provider Demographics
NPI:1912660440
Name:CORNEJO, EDGAR D (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:EDGAR
Middle Name:D
Last Name:CORNEJO
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:EDGAR
Other - Middle Name:DE JESUS
Other - Last Name:CORNEJO LOMELI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHYSICIAN ASSISTANT
Mailing Address - Street 1:14175 W INDIAN SCHOOL RD STE B4-120
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-8407
Mailing Address - Country:US
Mailing Address - Phone:956-222-7774
Mailing Address - Fax:
Practice Address - Street 1:14175 W INDIAN SCHOOL RD STE B4-120
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-8407
Practice Address - Country:US
Practice Address - Phone:956-222-7774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-21
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1100-P.A.363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant