Provider Demographics
NPI:1215693759
Name:CORNELL, TYLER A (IDC)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:A
Last Name:CORNELL
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 WALNUT HILLS DR
Mailing Address - Street 2:
Mailing Address - City:RICHLANDS
Mailing Address - State:NC
Mailing Address - Zip Code:28574-8346
Mailing Address - Country:US
Mailing Address - Phone:760-453-4511
Mailing Address - Fax:
Practice Address - Street 1:PSC 20090
Practice Address - Street 2:
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28542-0090
Practice Address - Country:US
Practice Address - Phone:760-453-4511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-09
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
12156937591710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman