Healthcare Provider Details

I. General information

NPI: 1841284635
Provider Name (Legal Business Name): JAMES S MACKIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 04/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2761 COMMERCIAL WAY
ROCK SPRINGS WY
82901-4753
US

IV. Provider business mailing address

1954 FT UNION BLVD 107
SALT LAKE CITY UT
84121-6800
US

V. Phone/Fax

Practice location:
  • Phone: 307-382-6873
  • Fax: 307-382-6869
Mailing address:
  • Phone: 801-993-9527
  • Fax: 801-733-5618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number162010-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: