Provider Demographics
NPI:1114573151
Name:ILEA, CORNELIU MIRCEA
Entity type:Individual
Prefix:
First Name:CORNELIU
Middle Name:MIRCEA
Last Name:ILEA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:CORNELIUS
Other - Middle Name:MIRCEA
Other - Last Name:ILEA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 911
Mailing Address - Street 2:
Mailing Address - City:BRATTLEBORO
Mailing Address - State:VT
Mailing Address - Zip Code:05302-0911
Mailing Address - Country:US
Mailing Address - Phone:207-303-3200
Mailing Address - Fax:
Practice Address - Street 1:11 ROCK ROW STE 120
Practice Address - Street 2:
Practice Address - City:WESTBROOK
Practice Address - State:ME
Practice Address - Zip Code:04092-4877
Practice Address - Country:US
Practice Address - Phone:207-303-3300
Practice Address - Fax:207-250-2139
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-15
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA2418363A00000X
NH1619363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty