Provider Demographics
NPI:1891810099
Name:MCCORKLE, GARY L (PA)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:L
Last Name:MCCORKLE
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:3431 BROADWAY ST
Mailing Address - Street 2:A8
Mailing Address - City:AMERICAN CANYON
Mailing Address - State:CA
Mailing Address - Zip Code:94503-1228
Mailing Address - Country:US
Mailing Address - Phone:707-731-1108
Mailing Address - Fax:707-652-2679
Practice Address - Street 1:3431 BROADWAY ST
Practice Address - Street 2:A8
Practice Address - City:AMERICAN CANYON
Practice Address - State:CA
Practice Address - Zip Code:94503-1228
Practice Address - Country:US
Practice Address - Phone:707-731-1108
Practice Address - Fax:707-652-2679
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2014-12-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPA17910CA363A00000X
CAPA17910363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant