Provider Demographics
NPI:1497436596
Name:MACKAY, GREGORY PAUL (APRN)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:PAUL
Last Name:MACKAY
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 DOLORES CIR
Mailing Address - Street 2:
Mailing Address - City:POMFRET CENTER
Mailing Address - State:CT
Mailing Address - Zip Code:06259-1243
Mailing Address - Country:US
Mailing Address - Phone:860-230-7947
Mailing Address - Fax:
Practice Address - Street 1:326 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-2740
Practice Address - Country:US
Practice Address - Phone:860-889-8331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-31
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT12218363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program