Active NPI
Shannon L Cornwell, PA
- Physician Assistant
- Fullerton, CA
National Provider Identifier
1902961626
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physician Assistant
- License
- PA17022
- Practice address
- 101 E Valencia Mesa Dr
Em Dept
Fullerton, CA 92835-3809 - Phone
- (714) 992-3965
- NPI assigned
- Dec 22, 2006
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physician Assistant | 363A00000X | PA17022 | CA | Primary |
Addresses
Primary practice location
101 E Valencia Mesa Dr
Em Dept
Fullerton, CA 92835-3809
Mailing address
4401 W Memorial Rd
Suite 121
Oklahoma City, OK 73134-1785
Phone (405) 751-4664
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| WPA17022A | Medicaid | CA | |
| 330311953 | Other | CA | TRICARE |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in CA
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: Yes
- Hospice: No
Enrollment records 1
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Physician Assistant
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 17022 | CA | MD | Speech-Language Pathologist |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- Emergency Medicine Physician
- Fullerton, CA
- NPI 1720190804
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1166745600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1236729600000",
"number": "1902961626",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4401 W MEMORIAL RD",
"address_2": "SUITE 121",
"city": "OKLAHOMA CITY",
"state": "OK",
"postal_code": "731341785",
"telephone_number": "405-751-4664",
"fax_number": "405-749-4561"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "101 E VALENCIA MESA DR",
"address_2": "EM DEPT",
"city": "FULLERTON",
"state": "CA",
"postal_code": "928353809",
"telephone_number": "714-992-3965"
}
],
"practiceLocations": [],
"basic": {
"last_name": "CORNWELL",
"first_name": "SHANNON",
"middle_name": "L",
"credential": "PA",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2006-12-22",
"last_updated": "2009-03-11",
"status": "A"
},
"taxonomies": [
{
"code": "363A00000X",
"taxonomy_group": "",
"desc": "Physician Assistant",
"state": "CA",
"license": "PA17022",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "WPA17022A",
"state": "CA"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "TRICARE",
"identifier": "330311953",
"state": "CA"
}
],
"endpoints": [],
"other_names": []
}Other providers in Fullerton, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 11, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.