Basic Information
| Provider Information | |||||||||
| NPI: | 1861647000 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MACKNICK | ||||||||
| FirstName: | PATRICK | ||||||||
| MiddleName: | ANDREW | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1234 E DUPONT RD | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468251545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603739965 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1818 CAREW ST | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468054788 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604836448 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2008 | ||||||||
| LastUpdateDate: | 11/20/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PENDING | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 000000614685 | 01 | IN | ANTHEM | OTHER | P00755205 | 01 | IN | MEDICARE RR | OTHER |