Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 2086S0102X | Surgical Critical Care | 46604 | AZ |
Y | 2086S0102X | Surgical Critical Care | L6843 | TX |
NPI | 1154438133 |
---|---|
Provider Name | Michael Corneille |
First Address | San Antonio, TX 78224-1337 |
Second Address | San Antonio, TX 78251-4501 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/08/2006 |
Last Update Date | 09/04/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
163414909 | (05) | TX |
P02601720 | MCRR (01) | TX |