=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477817203
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREW ROBERT MACKNAIR PA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2012
-----------------------------------------------------
Last Update Date | 12/08/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 378 MAPLE AVE
-----------------------------------------------------
City | SHREWSBURY
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01545-2675
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-595-2513
-----------------------------------------------------
Fax | 508-595-2021
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5 NEPONSET ST ATTN: MEDICAL STAFF SERVICES
-----------------------------------------------------
City | WORCESTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01606-2714
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-852-0600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------