Provider Demographics
NPI:1962289470
Name:CORNOG, KENNETH LAKE
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:LAKE
Last Name:CORNOG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3250 SE 15TH AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-2358
Mailing Address - Country:US
Mailing Address - Phone:518-409-6158
Mailing Address - Fax:
Practice Address - Street 1:3231 SE 50TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-2248
Practice Address - Country:US
Practice Address - Phone:503-238-5203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-11
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program