Provider Demographics
NPI:1154690014
Name:PAULSON, MACKENZIE RAE (PA-C)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:RAE
Last Name:PAULSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MACKENZIE
Other - Middle Name:
Other - Last Name:VERMILLION
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:168 N CASEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:PIGEON
Mailing Address - State:MI
Mailing Address - Zip Code:48755-9415
Mailing Address - Country:US
Mailing Address - Phone:989-453-2141
Mailing Address - Fax:989-453-2559
Practice Address - Street 1:168 N CASEVILLE RD
Practice Address - Street 2:
Practice Address - City:PIGEON
Practice Address - State:MI
Practice Address - Zip Code:48755-9415
Practice Address - Country:US
Practice Address - Phone:989-453-2141
Practice Address - Fax:989-453-2559
Is Sole Proprietor?:No
Enumeration Date:2011-12-22
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006273363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP09650007Medicare PIN