Provider Demographics
NPI:1356318265
Name:MACKEAN, THOMAS ALEXANDEER (FNPC)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:ALEXANDEER
Last Name:MACKEAN
Suffix:
Gender:M
Credentials:FNPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 889
Mailing Address - Street 2:
Mailing Address - City:LAKE PARK
Mailing Address - State:GA
Mailing Address - Zip Code:31636-0889
Mailing Address - Country:US
Mailing Address - Phone:229-242-9003
Mailing Address - Fax:229-242-0490
Practice Address - Street 1:704 GIL HARBIN INDUSTRIAL BLVD
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31601-6513
Practice Address - Country:US
Practice Address - Phone:229-242-9003
Practice Address - Fax:229-242-0490
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-01
Last Update Date:2015-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN146046363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA618616123AMedicaid
Q60248Medicare UPIN
GA50BBLLLMedicare PIN