Healthcare Provider Details

I. General information

NPI: 1295718336
Provider Name (Legal Business Name): A. CLINTON MACKINNEY MD, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/22/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 2ND ST SE
LITTLE FALLS MN
56345-3505
US

IV. Provider business mailing address

33921 N 91ST AVE
SAINT JOSEPH MN
56374
US

V. Phone/Fax

Practice location:
  • Phone: 320-632-5441
  • Fax:
Mailing address:
  • Phone: 320-363-8150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number27914
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: