Provider Demographics
NPI:1457556490
Name:MCCORMAC, JOAN STILLMAN (PAC)
Entity Type:Individual
Prefix:MRS
First Name:JOAN
Middle Name:STILLMAN
Last Name:MCCORMAC
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4544 E ROCKRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-1721
Mailing Address - Country:US
Mailing Address - Phone:602-852-0473
Mailing Address - Fax:
Practice Address - Street 1:7601 IMPERIAL HWY
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90242-3456
Practice Address - Country:US
Practice Address - Phone:562-401-6210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15308363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant