Provider Demographics
NPI:1932973856
Name:KORNBLAU, CAROLINA BENCOSME (PA-C)
Entity type:Individual
Prefix:
First Name:CAROLINA
Middle Name:BENCOSME
Last Name:KORNBLAU
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CAROLINA
Other - Middle Name:
Other - Last Name:BENCOSME NUNEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:115 SOMERSET DR
Mailing Address - Street 2:
Mailing Address - City:BLUE BELL
Mailing Address - State:PA
Mailing Address - Zip Code:19422-1451
Mailing Address - Country:US
Mailing Address - Phone:856-397-3290
Mailing Address - Fax:
Practice Address - Street 1:130 S BRYN MAWR AVE
Practice Address - Street 2:
Practice Address - City:BRYN MAWR
Practice Address - State:PA
Practice Address - Zip Code:19010-3121
Practice Address - Country:US
Practice Address - Phone:484-337-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-10
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA006743363A00000X
PAMA065228363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant