Basic Information
| Provider Information | |||||||||
| NPI: | 1730569740 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CORNELIO | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 711 COTTAGE GROVE RD | ||||||||
| Address2: | |||||||||
| City: | BLOOMFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060023060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602428756 | ||||||||
| FaxNumber: | 8602423052 | ||||||||
| Practice Location | |||||||||
| Address1: | 711 COTTAGE GROVE RD | ||||||||
| Address2: | |||||||||
| City: | BLOOMFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060023060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602428756 | ||||||||
| FaxNumber: | 8602423052 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2015 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 363AM0700X | 3334 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 1730569740 | 05 | CT | MEDICAID | D400225889 | 01 | MEDICARE | OTHER |