Basic Information
| Provider Information | |||||||||
| NPI: | 1558028027 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACKEY | ||||||||
| FirstName: | EBAN | ||||||||
| MiddleName: | JAMES | ||||||||
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| NameSuffix: | II | ||||||||
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| Mailing Information | |||||||||
| Address1: | 544 EAST DR | ||||||||
| Address2: | |||||||||
| City: | MARSHALL | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490681363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2692742963 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3475 BELLE CHASE WAY | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489114252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5178823732 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2021 | ||||||||
| LastUpdateDate: | 03/22/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 4704280061 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.