MEDICARE: DR. TAYLOR CORNWELL DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	R4137	AZ
2	207P00000X	Emergency Medicine Physician	000000	AZ
3	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1861186918
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TAYLOR CORNWELL DO

Provider Business Mailing Address
First Line	:	5480 ROADRUNNER AVE
Second Line	:
City	:	KINGMAN
State	:	AZ
Zip	:	86409
Country	:	US
Telephone Number	:	619-764-9654
Fax Number	:

Provider Business Practice Location Address
First Line	:	3269 N STOCKTON HILL RD
Second Line	:
City	:	KINGMAN
State	:	AZ
Zip	:	86409-3619
Country	:	US
Telephone Number	:	928-263-4466
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/02/2023
Last Update Date	:	01/05/2026

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