Provider Demographics
NPI:1285916437
Name:MCKINNON, MEAGAN ELISE (PA-C)
Entity type:Individual
Prefix:
First Name:MEAGAN
Middle Name:ELISE
Last Name:MCKINNON
Suffix:
Gender:F
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:PO BOX 2876
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31776-2876
Mailing Address - Country:US
Mailing Address - Phone:229-891-9131
Mailing Address - Fax:
Practice Address - Street 1:4 LIVE OAK CT
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-6783
Practice Address - Country:US
Practice Address - Phone:229-785-2400
Practice Address - Fax:229-502-9793
Is Sole Proprietor?:No
Enumeration Date:2011-09-14
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA008711363AM0700X
GAAT001938174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA008711OtherLICENSE