Provider Demographics
NPI:1477804854
Name:MACKEN, MISTY L (PA-C)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:L
Last Name:MACKEN
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 1:200 DELAFIELD RD
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15215-3205
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 DELAFIELD RD
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15215-3205
Practice Address - Country:US
Practice Address - Phone:412-784-5888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-26
Last Update Date:2015-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016055363A00000X
PAMA056858363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant