Provider Demographics
NPI:1477520906
Name:MACKO, ANDREW (PAC)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:MACKO
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 NEW LONDON AVE
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02920-3036
Mailing Address - Country:US
Mailing Address - Phone:401-270-3232
Mailing Address - Fax:401-383-9480
Practice Address - Street 1:1150 NEW LONDON AVE
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02920-3036
Practice Address - Country:US
Practice Address - Phone:401-270-3232
Practice Address - Fax:401-383-9480
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-03
Last Update Date:2011-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPA00295363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7010647Medicaid
RI9790039451OtherMEDICARE PTAN
RIP83688Medicare UPIN
RI007010647Medicare ID - Type UnspecifiedMEDICARE