Provider Demographics
NPI:1225681620
Name:MOMBERGER, MCKENZIE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MCKENZIE
Middle Name:
Last Name:MOMBERGER
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 1:2946 E BANNER GATEWAY DRIVE
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-2165
Mailing Address - Country:US
Mailing Address - Phone:480-256-6444
Mailing Address - Fax:480-256-3682
Practice Address - Street 1:2946 E BANNER GATEWAY DRIVE
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2165
Practice Address - Country:US
Practice Address - Phone:480-256-6444
Practice Address - Fax:480-256-3682
Is Sole Proprietor?:No
Enumeration Date:2019-07-24
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
AZ9119363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant