Provider Demographics
NPI:1205506508
Name:MCCORMACK, PATRICIA MARIE
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:MARIE
Last Name:MCCORMACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 WOODMERE BLVD
Mailing Address - Street 2:
Mailing Address - City:WOODMERE
Mailing Address - State:NY
Mailing Address - Zip Code:11598-2035
Mailing Address - Country:US
Mailing Address - Phone:516-295-1340
Mailing Address - Fax:516-295-1180
Practice Address - Street 1:321 WOODMERE BLVD
Practice Address - Street 2:
Practice Address - City:WOODMERE
Practice Address - State:NY
Practice Address - Zip Code:11598-2035
Practice Address - Country:US
Practice Address - Phone:516-295-1340
Practice Address - Fax:516-295-1180
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-17
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY423800921174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty