Provider Demographics
NPI:1518496280
Name:MACE, MEGAN LEE (PA-C, ATC)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:LEE
Last Name:MACE
Suffix:
Gender:F
Credentials:PA-C, ATC
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:LEE
Other - Last Name:DEROY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:54275 FOREST GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-4847
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:53880 CARMICHAEL DR
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-1567
Practice Address - Country:US
Practice Address - Phone:574-247-9441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-07
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1003718A363A00000X
2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN10003718AOtherIPLA