MEDICARE: LEE RICHERSON MACKIN PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AS0400X	Surgical Physician Assistant	PA-508	AL
2	363AS0400X	Surgical Physician Assistant	5062	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1235293804
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEE RICHERSON MACKIN PA-C

Provider Business Mailing Address
First Line	:	13100 N WESTERN AVE STE 303
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73114-1432
Country	:	US
Telephone Number	:	800-781-1220
Fax Number	:	888-678-8616

Provider Business Practice Location Address
First Line	:	13100 N WESTERN AVE STE 303
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73114-1432
Country	:	US
Telephone Number	:	800-781-1220
Fax Number	:	888-678-8616

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/20/2006
Last Update Date	:	08/21/2023

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