Provider Demographics
NPI:1124562012
Name:MACKAY, PAMELA D (FNP-C)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:D
Last Name:MACKAY
Suffix:
Gender:F
Credentials:FNP-C
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 847522
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-7522
Mailing Address - Country:US
Mailing Address - Phone:903-531-5000
Mailing Address - Fax:
Practice Address - Street 1:2026 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:TX
Practice Address - Zip Code:75766-5822
Practice Address - Country:US
Practice Address - Phone:903-586-5678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-12
Last Update Date:2018-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP132740363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8HL389OtherBCBS
TX75-1976930-005OtherTRICARE
TX8462MBOtherBCBS
TXP01787234OtherRAIL ROAD MEDICARE
TXP01938229OtherMEDICARE RAIL ROAD
TX369920901Medicaid
TX369920902Medicaid
TX552857YMAFOtherMEDICARE
TX752616977020OtherTRICARE