Provider Demographics
NPI:1174277966
Name:MCCORMICK, JOHN KELLY (PA)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:KELLY
Last Name:MCCORMICK
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:436 CROMWELL WAY
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-4302
Mailing Address - Country:US
Mailing Address - Phone:502-415-2447
Mailing Address - Fax:
Practice Address - Street 1:740 S LIMESTONE STE B101
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-4302
Practice Address - Country:US
Practice Address - Phone:859-323-5661
Practice Address - Fax:859-323-6411
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-09
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTC316363AM0700X, 363AS0400X, 363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program