Provider Demographics
NPI:1942781158
Name:MCCORMICK, BRIAN GERALD (AGACNP-BC)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:GERALD
Last Name:MCCORMICK
Suffix:
Gender:M
Credentials:AGACNP-BC
Other - Prefix:
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Mailing Address - Street 1:901 E 104TH ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64131-4517
Mailing Address - Country:US
Mailing Address - Phone:816-502-7117
Mailing Address - Fax:816-932-9670
Practice Address - Street 1:4600 COLLEGE BLVD STE 103
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66211-1606
Practice Address - Country:US
Practice Address - Phone:913-215-5008
Practice Address - Fax:913-297-1202
Is Sole Proprietor?:No
Enumeration Date:2018-08-25
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KS78736363LF0000X
MO2019015044363LF0000X
MO2013031549163WE0003X
KS14-133095-111163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WE0003XNursing Service ProvidersRegistered NurseEmergency
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSK02-98-0483OtherSTATE DRIVER'S LICENSE
MO2013031549OtherRN LICENSE NUMBER