Healthcare Provider Details

I. General information

NPI: 1972373785
Provider Name (Legal Business Name): MACKINSEY DIANE JOHNSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2024
Last Update Date: 03/05/2026
Certification Date: 03/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 FAYETTEVILLE ST
DURHAM NC
27707-2398
US

IV. Provider business mailing address

3207 GREGORY MANOR CT
CARY NC
27518-7152
US

V. Phone/Fax

Practice location:
  • Phone: 919-956-4000
  • Fax:
Mailing address:
  • Phone: 336-977-6537
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-14614
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: