Provider Demographics
NPI:1568005387
Name:PROBASCO, MACKAYLA RENEE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:MACKAYLA
Middle Name:RENEE
Last Name:PROBASCO
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 1:53 IVINS DR
Mailing Address - Street 2:
Mailing Address - City:NEW EGYPT
Mailing Address - State:NJ
Mailing Address - Zip Code:08533-2810
Mailing Address - Country:US
Mailing Address - Phone:732-644-4029
Mailing Address - Fax:
Practice Address - Street 1:911 SUNSET RD
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NJ
Practice Address - Zip Code:08016-2250
Practice Address - Country:US
Practice Address - Phone:609-387-8787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-24
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00550100363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical