Healthcare Provider Details

I. General information

NPI: 1356852164
Provider Name (Legal Business Name): TIMOTHY NEAL CORNWALL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2017
Last Update Date: 06/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 W 5TH AVE
SPOKANE WA
99204
US

IV. Provider business mailing address

8408 E FLEMING RD
FAIRFIELD WA
99012-9710
US

V. Phone/Fax

Practice location:
  • Phone: 509-473-7626
  • Fax:
Mailing address:
  • Phone: 509-723-5188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0000X
TaxonomyPain Management Registered Nurse
License NumberRN00168846
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP60807265
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: