Healthcare Provider Details

I. General information

NPI: 1528029246
Provider Name (Legal Business Name): PAUL S MACKINNON NP
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 LAKE AVE N DEPARTMENT OF EMERGENCY MEDICINE
WORCESTER MA
01655-0002
US

IV. Provider business mailing address

PO BOX 62 TURNPIKE STATION
SHREWSBURY MA
01545-0062
US

V. Phone/Fax

Practice location:
  • Phone: 508-856-5256
  • Fax:
Mailing address:
  • Phone: 508-334-8815
  • Fax: 508-334-5374

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number187538
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0391671
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: