Provider Demographics
NPI:1689655466
Name:MACKIE, TIMOTHY A (PA)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:A
Last Name:MACKIE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:2695 ROCKY MOUNTAIN AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-9071
Mailing Address - Country:US
Mailing Address - Phone:970-624-4451
Mailing Address - Fax:970-490-4199
Practice Address - Street 1:13631 COLORADO BLVD
Practice Address - Street 2:
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80602-7051
Practice Address - Country:US
Practice Address - Phone:303-252-2960
Practice Address - Fax:303-252-2964
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO1718363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO019498OtherKAISER COMMERCIAL NUMBER
CO12839701Medicaid
COCOA105776Medicare PIN