Provider Demographics
NPI:1437637030
Name:MCCORMACK, MOIRA (PA-C)
Entity Type:Individual
Prefix:
First Name:MOIRA
Middle Name:
Last Name:MCCORMACK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 80 BOX 10189
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96367-0004
Mailing Address - Country:US
Mailing Address - Phone:806-861-8414
Mailing Address - Fax:
Practice Address - Street 1:18TH MEDICAL GROUP
Practice Address - Street 2:UNIT 5142
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96368-5142
Practice Address - Country:US
Practice Address - Phone:315-630-5412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-06
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1153398363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant