Provider Demographics
NPI:1003872417
Name:MACKEN, PATRICK D (MD)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:D
Last Name:MACKEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 ELDERBERRY LN
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-9425
Mailing Address - Country:US
Mailing Address - Phone:715-832-9801
Mailing Address - Fax:
Practice Address - Street 1:1425 ELDERBERRY LN
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-9425
Practice Address - Country:US
Practice Address - Phone:715-832-9801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20307207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31073900Medicaid
B54732Medicare UPIN
WI31073900Medicaid