Healthcare Provider Details

I. General information

NPI: 1144404187
Provider Name (Legal Business Name): NATHAN KENYON CORNWALL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2007
Last Update Date: 05/10/2021
Certification Date: 05/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36000 DARNALL LOOP DARNALL ARMY MEDICAL CENTER
FORT HOOD TX
76544
US

IV. Provider business mailing address

36000 DARNALL LOOP DARNALL ARMY MEDICAL CENTER
FORT HOOD TX
76544
US

V. Phone/Fax

Practice location:
  • Phone: 254-288-8025
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1078945
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: