Provider Demographics
NPI:1417599580
Name:MACKEY, KERRY KELDON SR
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:KELDON
Last Name:MACKEY
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 NORTHVIEW DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLESEX
Mailing Address - State:NC
Mailing Address - Zip Code:27557-9470
Mailing Address - Country:US
Mailing Address - Phone:501-830-7400
Mailing Address - Fax:
Practice Address - Street 1:3610 BUSH ST
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7511
Practice Address - Country:US
Practice Address - Phone:919-876-3130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-10
Last Update Date:2023-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC001009499363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant