Provider Demographics
NPI:1790853331
Name:MACKEY, NANCY MARLENE (PA)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:MARLENE
Last Name:MACKEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1222
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-1222
Mailing Address - Country:US
Mailing Address - Phone:907-235-7000
Mailing Address - Fax:907-235-4050
Practice Address - Street 1:4201 BARTLETT ST STE 202
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:AK
Practice Address - Zip Code:99603-7004
Practice Address - Country:US
Practice Address - Phone:907-235-7000
Practice Address - Fax:907-235-4050
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK211363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKK153383Medicare ID - Type UnspecifiedMEDICARE KACHEMAK BAY MED
AKK153381Medicare ID - Type UnspecifiedMEDICARE REDOUBT MEDICAL
AKR99027Medicare UPIN