Provider Demographics
NPI:1164505863
Name:MCKENNEY, CHRISTOPHER LEE (PA-C)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:LEE
Last Name:MCKENNEY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 BOULDERS PKWY STE 102
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23225-5515
Mailing Address - Country:US
Mailing Address - Phone:804-320-4243
Mailing Address - Fax:804-622-0552
Practice Address - Street 1:1000 BOULDERS PKWY STE 101
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23225-5515
Practice Address - Country:US
Practice Address - Phone:804-320-4243
Practice Address - Fax:804-622-0552
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701002996101YP2500X
VA0110004290363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005413583Medicaid