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NPI Code Detail

MEDICARE: MARK MCKINNEY PA-S

MEDICARE: MARK MCKINNEY PA-S
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 Assistant
2390200000XStudent in an Organized Health Care Education/Training Program

General Provider Information

NPI Number : 1437784139
Entity Type Code : Individual
Provider Name (Legal Business Name) : MARK MCKINNEY PA-S
Provider Business Mailing Address
First Line : 605 PARK ST
Second Line :
City : ANTIGO
State : WI
Zip : 54409-2743
Country : US
Telephone Number : 715-627-1111
Fax Number :
Provider Business Practice Location Address
First Line : 750 HIGHLAND AVE # HSLC1270
Second Line :
City : MADISON
State : WI
Zip : 53705-2221
Country : US
Telephone Number : 608-263-5620
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/03/2020
Last Update Date : 07/07/2020

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