Provider Demographics
NPI:1124593462
Name:STEEN, MACKENZIE (PA-C)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:STEEN
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:PO BOX 19677
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9677
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:217-545-7053
Practice Address - Street 1:315 W CARPENTER ST FL 2
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-4901
Practice Address - Country:US
Practice Address - Phone:217-545-8000
Practice Address - Fax:217-545-7053
Is Sole Proprietor?:No
Enumeration Date:2018-10-12
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-006755363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical