Provider Demographics
NPI:1154845717
Name:MACKORELL, CHRISTEN MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:CHRISTEN
Middle Name:MARIE
Last Name:MACKORELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CHRISTEN
Other - Middle Name:MARIE
Other - Last Name:HAIR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:843-789-1620
Mailing Address - Fax:843-724-2440
Practice Address - Street 1:180 WINGO WAY STE 301
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-1812
Practice Address - Country:US
Practice Address - Phone:843-884-0302
Practice Address - Fax:843-849-9308
Is Sole Proprietor?:No
Enumeration Date:2017-07-26
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2790363AS0400X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC3043PAMedicaid