Basic Information
| Provider Information | |||||||||
| NPI: | 1487680054 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCORMICK | ||||||||
| FirstName: | JANEL | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7638 | ||||||||
| Address2: | |||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598077638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067215600 | ||||||||
| FaxNumber: | 4067215600 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 W BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598024008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067215600 | ||||||||
| FaxNumber: | 4063273065 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2006 | ||||||||
| LastUpdateDate: | 01/12/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 315 | MT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 4300270 | 05 | MT | MEDICAID |