Healthcare Provider Details

I. General information

NPI: 1225081045
Provider Name (Legal Business Name): SUSAN A. MCKINNEY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 07/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1002 WISHARD BLVD FL 4
INDIANAPOLIS IN
46202-2872
US

IV. Provider business mailing address

8910 PURDUE RD STE 500
INDIANAPOLIS IN
46268-3161
US

V. Phone/Fax

Practice location:
  • Phone: 317-692-2323
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number10000139A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: