Provider Demographics
NPI:1699186312
Name:MCCORMACK, RIAN
Entity Type:Individual
Prefix:
First Name:RIAN
Middle Name:
Last Name:MCCORMACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:RIAN
Other - Middle Name:PATRICK
Other - Last Name:MCCORMACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:33 BOW ST
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02143-2937
Mailing Address - Country:US
Mailing Address - Phone:617-625-9992
Mailing Address - Fax:617-666-0662
Practice Address - Street 1:33 BOW ST
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02143-2937
Practice Address - Country:US
Practice Address - Phone:617-625-9992
Practice Address - Fax:617-666-0662
Is Sole Proprietor?:No
Enumeration Date:2014-05-15
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA4876363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant