Provider Demographics
NPI:1982610739
Name:CORNELIUS, JASON R (MD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:R
Last Name:CORNELIUS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9645 GROVE CIR N STE 100
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-4466
Mailing Address - Country:US
Mailing Address - Phone:763-302-4114
Mailing Address - Fax:763-302-4081
Practice Address - Street 1:9645 GROVE CIR N STE 100
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369
Practice Address - Country:US
Practice Address - Phone:763-302-4114
Practice Address - Fax:763-302-4081
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN485902084S0012X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1982610739Medicaid
MNP00733589OtherMEDICARE RAILROAD
MNP00733589OtherMEDICARE RAILROAD
MN786463000Medicaid