Provider Demographics
NPI:1154615052
Name:MACKILLOP, YVONNE NICOLE (PA-C)
Entity type:Individual
Prefix:MS
First Name:YVONNE
Middle Name:NICOLE
Last Name:MACKILLOP
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:YVONNE
Other - Middle Name:NICOLE
Other - Last Name:OTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:615 SHIPYARD BLVD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28412-6431
Mailing Address - Country:US
Mailing Address - Phone:910-399-3755
Mailing Address - Fax:910-202-9966
Practice Address - Street 1:615 SHIPYARD BLVD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28412-6431
Practice Address - Country:US
Practice Address - Phone:910-392-5634
Practice Address - Fax:910-392-5654
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-08
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-03558363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC261129OtherMEDCOST
NC4774937OtherAETNA
NCFH4002505OtherFIRST CAROLINA CARE
NC13482969OtherPHCS - MULTIPLAN
NC1154615052OtherHEALTHNET FEDERAL SERVICES
NC1154615052Medicaid
NC5947395OtherUNITED HEALTHCARE
NC7155880OtherCIGNA/GREATWEST