Provider Demographics
NPI:1679503247
Name:MACKLEY, JOSEPH S (CRNA)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:S
Last Name:MACKLEY
Suffix:
Gender:M
Credentials:CRNA
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 3776
Mailing Address - Street 2:
Mailing Address - City:PINEDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93650-3776
Mailing Address - Country:US
Mailing Address - Phone:559-436-0871
Mailing Address - Fax:559-436-5221
Practice Address - Street 1:7152 N SHARON AVE
Practice Address - Street 2:104
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3361
Practice Address - Country:US
Practice Address - Phone:559-447-4898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANA2200367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ03303ZMedicare ID - Type Unspecified