Provider Demographics
NPI:1780872028
Name:MCCORMACK, VICKI LYNN (PA C)
Entity type:Individual
Prefix:MRS
First Name:VICKI
Middle Name:LYNN
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 1:407 LIVE OAK ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BEAUFORT
Mailing Address - State:NC
Mailing Address - Zip Code:28516-1944
Mailing Address - Country:US
Mailing Address - Phone:252-728-2328
Mailing Address - Fax:252-728-2628
Practice Address - Street 1:407 LIVE OAK ST
Practice Address - Street 2:SUITE 1
Practice Address - City:BEAUFORT
Practice Address - State:NC
Practice Address - Zip Code:28516-1944
Practice Address - Country:US
Practice Address - Phone:252-728-2328
Practice Address - Fax:252-728-2628
Is Sole Proprietor?:No
Enumeration Date:2007-10-11
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-00907363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
2770846BOtherPTAN