Provider Demographics
NPI:1649211251
Name:MCCORMACK, LISA A (PA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:MCCORMACK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:A
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:850 COLUMBIA RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-1493
Mailing Address - Country:US
Mailing Address - Phone:440-808-8030
Mailing Address - Fax:440-808-8032
Practice Address - Street 1:850 COLUMBIA RD
Practice Address - Street 2:SUITE 300
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-1493
Practice Address - Country:US
Practice Address - Phone:440-808-8030
Practice Address - Fax:440-808-8032
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNCCPA1062953363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q45812Medicare UPIN
OHPA75851Medicare PIN