Provider Demographics
NPI:1164049201
Name:BISHOP, MAKENZIE
Entity Type:Individual
Prefix:
First Name:MAKENZIE
Middle Name:
Last Name:BISHOP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 W 1325 N STE 200
Mailing Address - Street 2:
Mailing Address - City:CEDAR CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84721-8179
Mailing Address - Country:US
Mailing Address - Phone:435-586-7676
Mailing Address - Fax:
Practice Address - Street 1:110 W 1325 N STE 200
Practice Address - Street 2:
Practice Address - City:CEDAR CITY
Practice Address - State:UT
Practice Address - Zip Code:84721-8179
Practice Address - Country:US
Practice Address - Phone:435-586-7676
Practice Address - Fax:435-586-2290
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-05
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11917253-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant