Healthcare Provider Details

I. General information

NPI: 1528402476
Provider Name (Legal Business Name): PETER NILES MCCORKELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2013
Last Update Date: 05/10/2024
Certification Date: 05/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 1ST AVE 2A31
NEW YORK NY
10029-7404
US

IV. Provider business mailing address

15010 39TH AVE NE
LAKE FOREST PARK WA
98155-7835
US

V. Phone/Fax

Practice location:
  • Phone: 212-423-6684
  • Fax:
Mailing address:
  • Phone: 206-227-5508
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA141452
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: