Basic Information
Provider Information | |||||||||
NPI: | 1154615052 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MACKILLOP | ||||||||
FirstName: | YVONNE | ||||||||
MiddleName: | NICOLE | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | OTT | ||||||||
OtherFirstName: | YVONNE | ||||||||
OtherMiddleName: | NICOLE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 615 SHIPYARD BLVD | ||||||||
Address2: |   | ||||||||
City: | WILMINGTON | ||||||||
State: | NC | ||||||||
PostalCode: | 284126431 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9103993755 | ||||||||
FaxNumber: | 9102029966 | ||||||||
Practice Location | |||||||||
Address1: | 615 SHIPYARD BLVD | ||||||||
Address2: |   | ||||||||
City: | WILMINGTON | ||||||||
State: | NC | ||||||||
PostalCode: | 284126431 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9103925634 | ||||||||
FaxNumber: | 9103925654 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/08/2011 | ||||||||
LastUpdateDate: | 04/08/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/08/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0010-03558 | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 261129 | 01 | NC | MEDCOST | OTHER | 4774937 | 01 | NC | AETNA | OTHER | FH4002505 | 01 | NC | FIRST CAROLINA CARE | OTHER | 13482969 | 01 | NC | PHCS - MULTIPLAN | OTHER | 1154615052 | 01 | NC | HEALTHNET FEDERAL SERVICES | OTHER | 1154615052 | 05 | NC |   | MEDICAID | 5947395 | 01 | NC | UNITED HEALTHCARE | OTHER | 7155880 | 01 | NC | CIGNA/GREATWEST | OTHER |