Basic Information
| Provider Information | |||||||||
| NPI: | 1053899682 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CORNELSON | ||||||||
| FirstName: | HUGH | ||||||||
| MiddleName: | COLBY | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 658 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305030658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707181122 | ||||||||
| FaxNumber: | 7705334786 | ||||||||
| Practice Location | |||||||||
| Address1: | 655 JESSE JEWELL PKWY SE | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305013756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705327092 | ||||||||
| FaxNumber: | 7705360383 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2018 | ||||||||
| LastUpdateDate: | 11/27/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN230883 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 003208648A | 05 | GA | MEDICAID | 003208648C | 05 | GA | MEDICAID | 003208648E | 05 | GA | MEDICAID | 1710460 | 01 | GA | WELLCARE | OTHER | 003208648B | 05 | GA | MEDICAID | 003208648D | 05 | GA | MEDICAID | 003208648F | 05 | GA | MEDICAID | 06083704 | 01 | GA | AMERIGROUP | OTHER |