Provider Demographics
NPI:1427117381
Name:CORNWALL, MICHAEL PAT (NURSE PRACTITIONER)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:PAT
Last Name:CORNWALL
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2416 EAST AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14610-2525
Mailing Address - Country:US
Mailing Address - Phone:585-442-4156
Mailing Address - Fax:
Practice Address - Street 1:4646 NINE MILE POINT RD
Practice Address - Street 2:
Practice Address - City:FAIRPORT
Practice Address - State:NY
Practice Address - Zip Code:14450-1163
Practice Address - Country:US
Practice Address - Phone:585-377-0350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF301165-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
500006563OtherRAILROAD PROVIDER NUMBER
H81090Medicare ID - Type Unspecified
NYS13570Medicare UPIN