Provider Demographics
NPI:1316023484
Name:MCCORMICK, ALLISON LACEY (MD)
Entity Type:Individual
Prefix:
First Name:ALLISON
Middle Name:LACEY
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 SIERRA COLLEGE DR
Mailing Address - Street 2:SUITE 235
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-5082
Mailing Address - Country:US
Mailing Address - Phone:530-273-6530
Mailing Address - Fax:530-273-3951
Practice Address - Street 1:3254 PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95602-2412
Practice Address - Country:US
Practice Address - Phone:530-888-1016
Practice Address - Fax:530-888-1346
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2008-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA71954207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0100570Medicaid
H92010Medicare UPIN
CAGR0100570Medicaid