Provider Demographics
NPI:1164966750
Name:MCCORD, LIANNA GRACE
Entity Type:Individual
Prefix:
First Name:LIANNA
Middle Name:GRACE
Last Name:MCCORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1340 WAVERLY AVENUE
Mailing Address - Street 2:
Mailing Address - City:FARMINGVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11738-1348
Mailing Address - Country:US
Mailing Address - Phone:631-885-1254
Mailing Address - Fax:
Practice Address - Street 1:1340 WAVERLY AVENUE
Practice Address - Street 2:
Practice Address - City:FARMINGVILLE
Practice Address - State:NY
Practice Address - Zip Code:11738-1348
Practice Address - Country:US
Practice Address - Phone:631-885-1254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-15
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020478-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant