Provider Demographics
NPI:1386703114
Name:MACKICHAN, KAREN L (MD)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:L
Last Name:MACKICHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KAREN
Other - Middle Name:L
Other - Last Name:HARRISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3601 S 6TH AVE
Mailing Address - Street 2:1-11C
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85723-0001
Mailing Address - Country:US
Mailing Address - Phone:520-792-1450
Mailing Address - Fax:520-629-4976
Practice Address - Street 1:3601 S 6TH AVE
Practice Address - Street 2:1-11C
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85723-0001
Practice Address - Country:US
Practice Address - Phone:520-792-1450
Practice Address - Fax:520-629-4976
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-07
Last Update Date:2016-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00026861207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA110544Medicaid
WA110544Medicaid
G115001124Medicare PIN