Provider Demographics
NPI:1487680054
Name:MCCORMICK, JANEL D (PA-C)
Entity Type:Individual
Prefix:
First Name:JANEL
Middle Name:D
Last Name:MCCORMICK
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:PO BOX 7638
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59807-7638
Mailing Address - Country:US
Mailing Address - Phone:406-721-5600
Mailing Address - Fax:406-721-5600
Practice Address - Street 1:500 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4008
Practice Address - Country:US
Practice Address - Phone:406-721-5600
Practice Address - Fax:406-327-3065
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT315363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT4300270Medicaid
MT000083145Medicare ID - Type Unspecified
P65411Medicare UPIN