Healthcare Provider Details

I. General information

NPI: 1699186312
Provider Name (Legal Business Name): RIAN MCCORMACK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: RIAN PATRICK MCCORMACK PA

II. Dates (important events)

Enumeration Date: 05/15/2014
Last Update Date: 05/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 BOW ST
SOMERVILLE MA
02143-2937
US

IV. Provider business mailing address

33 BOW ST
SOMERVILLE MA
02143-2937
US

V. Phone/Fax

Practice location:
  • Phone: 617-625-9992
  • Fax: 617-666-0662
Mailing address:
  • Phone: 617-625-9992
  • Fax: 617-666-0662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA4876
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: