Provider Demographics
NPI:1992034946
Name:MCCORMACK, KERIN A (PA-C)
Entity Type:Individual
Prefix:MS
First Name:KERIN
Middle Name:A
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 1:86 WREN ST
Mailing Address - Street 2:
Mailing Address - City:BARNWELL
Mailing Address - State:SC
Mailing Address - Zip Code:29812-1529
Mailing Address - Country:US
Mailing Address - Phone:803-259-5762
Mailing Address - Fax:803-259-3250
Practice Address - Street 1:209 ABBEVILLE AVE NW
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29801-3923
Practice Address - Country:US
Practice Address - Phone:803-306-1433
Practice Address - Fax:803-632-1209
Is Sole Proprietor?:No
Enumeration Date:2009-12-21
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1484207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAA4884OtherMEDICARE
SC1484OtherMEDICAL LICENSE
SC1338PAMedicaid