Provider Demographics
NPI:1407831944
Name:MCCORMICK, COLLEEN A (CRNA)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:A
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 WILDWOOD EST
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-5002
Mailing Address - Country:US
Mailing Address - Phone:518-561-2214
Mailing Address - Fax:
Practice Address - Street 1:216 LOGAN LN
Practice Address - Street 2:CRNA - MEDICAL DOCTOR ASSOCIATES
Practice Address - City:MAHOPAC
Practice Address - State:NY
Practice Address - Zip Code:10541-3650
Practice Address - Country:US
Practice Address - Phone:888-400-8878
Practice Address - Fax:845-621-1911
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101-0017589367500000X
NY5039101367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRA8271Medicare ID - Type Unspecified
VTVT9349Medicare ID - Type Unspecified