Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | 12140 | FL |
NPI | 1023148244 |
---|---|
Provider Name | Dr. Jan K Cornelius |
First Address | Tampa, FL 33629-6845 |
Second Address | Tampa, FL 33629-6845 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/03/2007 |
Last Update Date | 08/07/2007 |