Provider Demographics
NPI:1427080563
Name:MACKEY, SUSAN TARA (DC, PA-C)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:TARA
Last Name:MACKEY
Suffix:
Gender:F
Credentials:DC, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 MEDFORD AVE
Mailing Address - Street 2:
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-1281
Mailing Address - Country:US
Mailing Address - Phone:631-758-1910
Mailing Address - Fax:631-758-2371
Practice Address - Street 1:77 MEDFORD AVE
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-1281
Practice Address - Country:US
Practice Address - Phone:631-758-1910
Practice Address - Fax:631-758-2371
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX007538-1111N00000X
NY018994-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
P735820OtherOXFORD
NYC07538-4OtherWC
NYC0753YMOtherWC
605796OtherACN
929118NOtherMDC
80315OtherVYTRA
859940OtherGHI
8675557OtherCIGNA
2124488OtherAETNA
NY6I020569Y06Medicaid
NY6I020569Y06Medicaid
NYU68135Medicare UPIN
80315OtherVYTRA