Provider Demographics
NPI:1487124020
Name:MCMACKIN, KAITLYN JOLENA (PA-C)
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:JOLENA
Last Name:MCMACKIN
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 1:2101 HIGHWAY 90
Mailing Address - Street 2:
Mailing Address - City:GAUTIER
Mailing Address - State:MS
Mailing Address - Zip Code:39553-5340
Mailing Address - Country:US
Mailing Address - Phone:228-497-7576
Mailing Address - Fax:228-497-8869
Practice Address - Street 1:1124 OAKLEIGH RD
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-5716
Practice Address - Country:US
Practice Address - Phone:228-875-3778
Practice Address - Fax:228-875-9335
Is Sole Proprietor?:No
Enumeration Date:2018-11-27
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10002621A363A00000X
MSPA00439363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS005382709Medicaid