Provider Demographics
NPI:1710593397
Name:MCCORMACK, ELYSSA SUMMER (PA-C)
Entity Type:Individual
Prefix:
First Name:ELYSSA
Middle Name:SUMMER
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 1:101 E VALENCIA MESA DR
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-3809
Mailing Address - Country:US
Mailing Address - Phone:714-626-8500
Mailing Address - Fax:
Practice Address - Street 1:101 E VALENCIA MESA DR
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-3809
Practice Address - Country:US
Practice Address - Phone:714-626-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-19
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA58537363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant