Provider Demographics
NPI:1912152265
Name:MACKIE, SEAN PATRICK (PA-C)
Entity Type:Individual
Prefix:MR
First Name:SEAN
Middle Name:PATRICK
Last Name:MACKIE
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 1:4011 TALBOT RD S
Mailing Address - Street 2:SUITE 300
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-5773
Mailing Address - Country:US
Mailing Address - Phone:425-656-5060
Mailing Address - Fax:425-656-5047
Practice Address - Street 1:4011 TALBOT RD S
Practice Address - Street 2:SUITE 300
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-5773
Practice Address - Country:US
Practice Address - Phone:425-656-5060
Practice Address - Fax:425-656-5047
Is Sole Proprietor?:No
Enumeration Date:2008-11-28
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA 60056491363A00000X
WAPA60056491363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0243716OtherL&I
WA8538928Medicaid