Provider Demographics
NPI:1437784139
Name:MCKINNEY, MARK (PA-S)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MCKINNEY
Suffix:
Gender:M
Credentials:PA-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 PARK ST
Mailing Address - Street 2:
Mailing Address - City:ANTIGO
Mailing Address - State:WI
Mailing Address - Zip Code:54409-2743
Mailing Address - Country:US
Mailing Address - Phone:715-627-1111
Mailing Address - Fax:
Practice Address - Street 1:750 HIGHLAND AVE # HSLC1270
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-2221
Practice Address - Country:US
Practice Address - Phone:608-263-5620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-03
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant