Provider Demographics
NPI:1386070449
Name:KORNEL, ALEXANDER VADIMOVICH (LAC)
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:VADIMOVICH
Last Name:KORNEL
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:ALEXANDER
Other - Middle Name:VADIMOVICH
Other - Last Name:KRIVOBOK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LAC
Mailing Address - Street 1:4570 W 77TH ST STE 140
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-5004
Mailing Address - Country:US
Mailing Address - Phone:952-500-8733
Mailing Address - Fax:763-542-8142
Practice Address - Street 1:4570 W 77TH ST STE 140
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-5004
Practice Address - Country:US
Practice Address - Phone:952-500-8733
Practice Address - Fax:763-542-8142
Is Sole Proprietor?:No
Enumeration Date:2013-09-20
Last Update Date:2013-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1619171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist