Provider Demographics
NPI:1144792904
Name:BERRUS, MACKENZIE MEYER (PA-C)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:MEYER
Last Name:BERRUS
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 1:920 LARK DR
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12207-1398
Mailing Address - Country:US
Mailing Address - Phone:518-465-4771
Mailing Address - Fax:
Practice Address - Street 1:920 LARK DR
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12207-1398
Practice Address - Country:US
Practice Address - Phone:518-465-4771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-18
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022817363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant