Provider Demographics
NPI:1699731653
Name:MCCORMACK, SANDRA LEE (MD)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:LEE
Last Name:MCCORMACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2819 LYNN RD
Mailing Address - Street 2:
Mailing Address - City:TRYON
Mailing Address - State:NC
Mailing Address - Zip Code:28782-6681
Mailing Address - Country:US
Mailing Address - Phone:828-859-9783
Mailing Address - Fax:828-859-6856
Practice Address - Street 1:2819 LYNN RD
Practice Address - Street 2:
Practice Address - City:TRYON
Practice Address - State:NC
Practice Address - Zip Code:28782-6681
Practice Address - Country:US
Practice Address - Phone:828-859-9783
Practice Address - Fax:828-859-6856
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-26
Last Update Date:2009-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC26126207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8955881Medicaid
C81443Medicare UPIN
NC8955881Medicaid