Healthcare Provider Details

I. General information

NPI: 1316050875
Provider Name (Legal Business Name): SUZANNE RENEE CORNELIUS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 04/01/2024
Certification Date: 04/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8501 HARCOURT RD
INDIANAPOLIS IN
46260-2046
US

IV. Provider business mailing address

8501 HARCOURT RD
INDIANAPOLIS IN
46260-2046
US

V. Phone/Fax

Practice location:
  • Phone: 317-875-9105
  • Fax: 317-808-8802
Mailing address:
  • Phone: 317-875-9105
  • Fax: 317-875-8638

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: