Provider Demographics
NPI:1043900475
Name:MACKINAC, MADELINE ROSE
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:ROSE
Last Name:MACKINAC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 W LOMBARD ST
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52804-2029
Mailing Address - Country:US
Mailing Address - Phone:563-333-5827
Mailing Address - Fax:
Practice Address - Street 1:1320 W LOMBARD ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52804-2029
Practice Address - Country:US
Practice Address - Phone:563-333-5827
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-09
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant