Basic Information
Provider Information | |||||||||
NPI: | 1235199811 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KORNELY | ||||||||
FirstName: | SARA | ||||||||
MiddleName: | E | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | P.A. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3455 LUTHERAN PKWY STE 105 | ||||||||
Address2: |   | ||||||||
City: | WHEAT RIDGE | ||||||||
State: | CO | ||||||||
PostalCode: | 800336028 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3034566000 | ||||||||
FaxNumber: | 3038655788 | ||||||||
Practice Location | |||||||||
Address1: | 500 W 144TH AVE STE 230 | ||||||||
Address2: |   | ||||||||
City: | WESTMINSTER | ||||||||
State: | CO | ||||||||
PostalCode: | 800239328 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3036652600 | ||||||||
FaxNumber: | 3036652605 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/27/2006 | ||||||||
LastUpdateDate: | 03/17/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1759-023 | WI | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363A00000X | PA-3274 | CO | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 41990600 | 05 | WI |   | MEDICAID |