Provider Demographics
NPI:1255394581
Name:MCCORMICK, SCOTT MANWELL (CRNA)
Entity type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:MANWELL
Last Name:MCCORMICK
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2017 W HARBORLIGHT CT
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67204-2577
Mailing Address - Country:US
Mailing Address - Phone:316-832-2331
Mailing Address - Fax:316-755-1798
Practice Address - Street 1:2017 W HARBORLIGHT CT
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67204-2577
Practice Address - Country:US
Practice Address - Phone:316-832-2331
Practice Address - Fax:316-755-1798
Is Sole Proprietor?:No
Enumeration Date:2006-04-08
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS13-39046-091367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100252460EMedicaid
KS144564OtherBLUE SHIELD