Provider Demographics
NPI:1861647000
Name:MACKNICK, PATRICK ANDREW (PA-C)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:ANDREW
Last Name:MACKNICK
Suffix:
Gender:M
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 1:1234 E DUPONT RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1545
Mailing Address - Country:US
Mailing Address - Phone:260-373-9965
Mailing Address - Fax:
Practice Address - Street 1:1818 CAREW ST
Practice Address - Street 2:SUITE 250
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4788
Practice Address - Country:US
Practice Address - Phone:260-483-6448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-01
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INPENDING363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000614685OtherANTHEM
INP00755205OtherMEDICARE RR
IN000000614685OtherANTHEM