Basic Information
| Provider Information | |||||||||
| NPI: | 1285868570 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CORNELL | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2000 | ||||||||
| Address2: | |||||||||
| City: | EAST SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130574500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153625129 | ||||||||
| FaxNumber: | 3153625179 | ||||||||
| Practice Location | |||||||||
| Address1: | 1603 COURT ST | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132081834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154557591 | ||||||||
| FaxNumber: | 3154552446 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2009 | ||||||||
| LastUpdateDate: | 05/14/2009 | ||||||||
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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 | 225200000X | 005664 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.