Provider Demographics
NPI:1598823528
Name:CORNELIUS, CAROL S (PA-C)
Entity type:Individual
Prefix:MS
First Name:CAROL
Middle Name:S
Last Name:CORNELIUS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:CAROL
Other - Middle Name:S
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:912 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:GRANT
Mailing Address - State:NE
Mailing Address - Zip Code:69140-3099
Mailing Address - Country:US
Mailing Address - Phone:308-352-7100
Mailing Address - Fax:308-352-7290
Practice Address - Street 1:900 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:GRANT
Practice Address - State:NE
Practice Address - Zip Code:69140-3095
Practice Address - Country:US
Practice Address - Phone:308-352-7200
Practice Address - Fax:308-352-7290
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE931363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NEP24838Medicare UPIN