Basic Information
| Provider Information | |||||||||
| NPI: | 1902808785 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCKEE | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | JANE | ||||||||
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| Credential: | P.A.-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3702 NEW VISION DR BLDG B | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451703 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 8911 LIBERTY MILLS RD | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468046311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603739465 | ||||||||
| FaxNumber: | 2602669406 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2005 | ||||||||
| LastUpdateDate: | 12/11/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/11/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 10000469A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 970023100 | 01 | IN | RR MEDICARE | OTHER |