Provider Demographics
NPI:1902808785
Name:MCKEE, MARY JANE (PA-C)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JANE
Last Name:MCKEE
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 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8911 LIBERTY MILLS RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6311
Practice Address - Country:US
Practice Address - Phone:260-373-9465
Practice Address - Fax:260-266-9406
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000469A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN970023100OtherRR MEDICARE
IN1281330001Medicare NSC
IN970023100Medicare PIN
IN970023100OtherRR MEDICARE