Provider Demographics
NPI:1710748306
Name:MCCORMACK, AUSTIN P
Entity Type:Individual
Prefix:
First Name:AUSTIN
Middle Name:P
Last Name:MCCORMACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 6TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-1042
Mailing Address - Country:US
Mailing Address - Phone:360-459-8311
Mailing Address - Fax:
Practice Address - Street 1:4200 6TH AVE SE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-1042
Practice Address - Country:US
Practice Address - Phone:360-459-8311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-19
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP160963064225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant