Provider Demographics
NPI:1235273509
Name:MCKENZIE, WAYLAND WILSON (MD)
Entity Type:Individual
Prefix:
First Name:WAYLAND
Middle Name:WILSON
Last Name:MCKENZIE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 A BANNER AVE
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-3284
Mailing Address - Country:US
Mailing Address - Phone:336-273-8638
Mailing Address - Fax:336-274-0146
Practice Address - Street 1:500 A BANNER AVE
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-3284
Practice Address - Country:US
Practice Address - Phone:336-273-8638
Practice Address - Fax:336-274-0146
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC19760261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8957131Medicaid
NC8957131Medicaid