Provider Demographics
NPI:1811967219
Name:MCKEE, JODY KATHLEEN (PA)
Entity type:Individual
Prefix:
First Name:JODY
Middle Name:KATHLEEN
Last Name:MCKEE
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 1:1100 6TH ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CORALVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52241-1755
Mailing Address - Country:US
Mailing Address - Phone:319-337-4566
Mailing Address - Fax:319-337-4766
Practice Address - Street 1:1100 6TH ST
Practice Address - Street 2:SUITE 202
Practice Address - City:CORALVILLE
Practice Address - State:IA
Practice Address - Zip Code:52241-1755
Practice Address - Country:US
Practice Address - Phone:319-337-4566
Practice Address - Fax:319-337-4766
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001292363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2208108Medicaid
IA17541OtherBLUE CROSS BLUE SHIELD
IA391894814-02OtherTAX ID NUMBER
IA2208108Medicaid
IAP07714Medicare UPIN