Provider Demographics
NPI:1801864442
Name:MCCORMACK, KRISTIN L (PT)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:L
Last Name:MCCORMACK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 COUNTY ROUTE 64
Mailing Address - Street 2:
Mailing Address - City:MEXICO
Mailing Address - State:NY
Mailing Address - Zip Code:13114-3229
Mailing Address - Country:US
Mailing Address - Phone:315-963-5421
Mailing Address - Fax:315-963-7693
Practice Address - Street 1:19472 US ROUTE 11
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-5387
Practice Address - Country:US
Practice Address - Phone:315-782-6126
Practice Address - Fax:315-782-3816
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0243201174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRA5760Medicare ID - Type Unspecified