MEDICARE: PATRICK ANDREW MACKNICK PA-C

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
1	363A00000X	Physician Assistant	10001054A	IN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	P00755205	OTHER	IN	MEDICARE RR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000614685	OTHER	IN	ANTHEM

General Provider Information

NPI Number	:	1861647000
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PATRICK ANDREW MACKNICK PA-C

Provider Business Mailing Address
First Line	:	608 UNION CHAPEL RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-9357
Country	:	US
Telephone Number	:	260-482-5091
Fax Number	:

Provider Business Practice Location Address
First Line	:	11109 PARKVIEW PLAZA DR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-1701
Country	:	US
Telephone Number	:	260-482-5091
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/01/2008
Last Update Date	:	03/30/2026

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Directions to “ PATRICK ANDREW MACKNICK PA-C” Practice Location

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