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NPI Code Detail

MEDICARE: KERRY KELDON MACKEY SR.

MEDICARE: KERRY KELDON MACKEY SR.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363A00000XPhysician Assistant001009499NC

General Provider Information

NPI Number : 1417599580
Entity Type Code : Individual
Provider Name (Legal Business Name) : KERRY KELDON MACKEY SR.
Provider Business Mailing Address
First Line : 3835 N FREEWAY BLVD STE 100
Second Line :
City : SACRAMENTO
State : CA
Zip : 95834-1954
Country : US
Telephone Number : 919-876-3130
Fax Number :
Provider Business Practice Location Address
First Line : 4700 FALLS OF NEUSE RD STE 355
Second Line :
City : RALEIGH
State : NC
Zip : 27609-6275
Country : US
Telephone Number : 919-876-3130
Fax Number : 888-438-1446
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/10/2019
Last Update Date : 05/20/2026

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Directions to “ KERRY KELDON MACKEY SR. ” Practice Location

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