Basic Information
| Provider Information | |||||||||
| NPI: | 1942781158 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCORMICK | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | GERALD | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | AGACNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 901 E 104TH ST | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641314517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8165027117 | ||||||||
| FaxNumber: | 8169329670 | ||||||||
| Practice Location | |||||||||
| Address1: | 4600 COLLEGE BLVD STE 103 | ||||||||
| Address2: | |||||||||
| City: | OVERLAND PARK | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662111606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9132155008 | ||||||||
| FaxNumber: | 9132971202 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2018 | ||||||||
| LastUpdateDate: | 03/12/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 78736 | KS | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 2019015044 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 163WE0003X | 2013031549 | MO | N | Nursing Service Providers | Registered Nurse | Emergency | 163WE0003X | 14-133095-111 | KS | N | Nursing Service Providers | Registered Nurse | Emergency |
ID Information
| ID | Type | State | Issuer | Description | K02-98-0483 | 01 | KS | STATE DRIVER'S LICENSE | OTHER | 2013031549 | 01 | MO | RN LICENSE NUMBER | OTHER |