Healthcare Provider Details

I. General information

NPI: 1467798231
Provider Name (Legal Business Name): ROXANNE KAY CORNELIUS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2012
Last Update Date: 12/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 MIDTOWNE ST NE SUITE 110
GRAND RAPIDS MI
49503-5729
US

IV. Provider business mailing address

8849 TAMARISK CIRCLE
RICHLAND MI
49083
US

V. Phone/Fax

Practice location:
  • Phone: 616-588-8880
  • Fax:
Mailing address:
  • Phone: 269-501-3143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5601003078
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: