Provider Demographics
NPI:1245784180
Name:MCCORMICK, JOHN K (FNP)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:K
Last Name:MCCORMICK
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2200 BRYANT WILLIAMS DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-1121
Mailing Address - Country:US
Mailing Address - Phone:541-884-7746
Mailing Address - Fax:541-884-0848
Practice Address - Street 1:2200 BRYANT WILLIAMS DR
Practice Address - Street 2:SUITE 1
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-1121
Practice Address - Country:US
Practice Address - Phone:541-884-7746
Practice Address - Fax:541-884-0848
Is Sole Proprietor?:No
Enumeration Date:2016-08-09
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201604411NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP01702513OtherRAILROAD MEDICARE
OR500710776Medicaid
ORP01702513OtherRAILROAD MEDICARE