Provider Demographics
NPI:1225081045
Name:MCKINNEY, SUSAN A (PA-C)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:A
Last Name:MCKINNEY
Suffix:
Gender:F
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 1:8910 PURDUE RD
Mailing Address - Street 2:STE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-3161
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1002 WISHARD BLVD FL 4
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-2872
Practice Address - Country:US
Practice Address - Phone:317-692-2323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000139A363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000506703OtherBC/BS PIN
IN200856130OtherMEDICAID GROUP
P00383030OtherRAILROAD MEDICARE PIN
INDF5450OtherRAILROAD GROUP
IN248600AMedicare Oscar/Certification
IN248600AMedicare PIN
IN000000506703OtherBC/BS PIN
INR33225Medicare UPIN