MEDICARE: SARAH CHRISTINA CORNELL PA-S

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1619667813
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SARAH CHRISTINA CORNELL PA-S

Provider Business Mailing Address
First Line	:	2145 WATERTOWN RD
Second Line	:
City	:	LONG LAKE
State	:	MN
Zip	:	55356-9422
Country	:	US
Telephone Number	:	612-849-4559
Fax Number	:

Provider Business Practice Location Address
First Line	:	2145 WATERTOWN RD
Second Line	:
City	:	LONG LAKE
State	:	MN
Zip	:	55356-9422
Country	:	US
Telephone Number	:	612-849-4559
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/10/2023
Last Update Date	:	05/10/2023

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