Provider Demographics
NPI:1023049962
Name:MCCORMACK, PATRICIA (APN)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:MCCORMACK
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1086
Mailing Address - Street 2:
Mailing Address - City:PLEASANTVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08232-6086
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6010 BLACK HORSE PIKE
Practice Address - Street 2:
Practice Address - City:EGG HARBOR TWP
Practice Address - State:NJ
Practice Address - Zip Code:08234-9752
Practice Address - Country:US
Practice Address - Phone:609-272-8580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00030700363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0052175Medicaid
NJ087306CB8Medicare PIN
Q33485Medicare UPIN