1023271632 NPI number — MACKENZIE ANNE MCCROREY PA-C

Table of content: MACKENZIE ANNE MCCROREY PA-C (NPI 1023271632)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023271632 NPI number — MACKENZIE ANNE MCCROREY PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCROREY
Provider First Name:
MACKENZIE
Provider Middle Name:
ANNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023271632
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/10/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
852 SE 59TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97215-2001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-925-5903
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10000 SE MAIN ST STE 365
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97216-2474
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-261-4430
Provider Business Practice Location Address Fax Number:
503-261-4436
Provider Enumeration Date:
07/03/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  085003524 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AS0400X , with the licence number: 085003524 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AS0400X , with the licence number: PA195380 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P01216933 . This is a "MEDICARE RAILROAD (PROVIDER PTAN)" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 206147 . This is a "MEDICARE (GROUP PTAN)" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 206147235 . This is a "MEDICARE (INDIVIDUAL)" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: CA4748 . This is a "MEDICARE RAILROAD (GROUP PTAN)" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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