Healthcare Provider Details

I. General information

NPI: 1619367786
Provider Name (Legal Business Name): ANTHONY CORNEJO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2015
Last Update Date: 04/27/2022
Certification Date: 04/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1217 1ST ST NW
ALBUQUERQUE NM
87102-1529
US

IV. Provider business mailing address

11059 E BETHANY DR
AURORA CO
80014-2622
US

V. Phone/Fax

Practice location:
  • Phone: 505-766-5197
  • Fax:
Mailing address:
  • Phone: 303-617-2300
  • Fax: 303-617-2365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number092370245
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: