Provider Demographics
NPI:1790226983
Name:MCKINNON, MITCHELL A
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:A
Last Name:MCKINNON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 SALINA MEADOWS PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13212-4516
Mailing Address - Country:US
Mailing Address - Phone:315-464-2000
Mailing Address - Fax:315-464-2010
Practice Address - Street 1:4900 BROAD ROAD
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13215
Practice Address - Country:US
Practice Address - Phone:315-492-5437
Practice Address - Fax:315-492-5502
Is Sole Proprietor?:No
Enumeration Date:2017-03-20
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY307021207PP0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine