Healthcare Provider Details

I. General information

NPI: 1457171688
Provider Name (Legal Business Name): MAKINSEY CALISTO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2024
Last Update Date: 10/14/2024
Certification Date: 10/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 MICHIGAN AVE
LOGANSPORT IN
46947-1528
US

IV. Provider business mailing address

4210 PEARSON DR
WESTFIELD IN
46062-6125
US

V. Phone/Fax

Practice location:
  • Phone: 574-753-7541
  • Fax:
Mailing address:
  • Phone: 574-721-1708
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: