Provider Demographics
NPI:1235852286
Name:PETERSON, MACKENZIE GRACE
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:GRACE
Last Name:PETERSON
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 1:26 CREST WOOD CIR
Mailing Address - Street 2:
Mailing Address - City:PITTSFORD
Mailing Address - State:NY
Mailing Address - Zip Code:14534-9556
Mailing Address - Country:US
Mailing Address - Phone:585-329-9383
Mailing Address - Fax:
Practice Address - Street 1:26 CREST WOOD CIR
Practice Address - Street 2:
Practice Address - City:PITTSFORD
Practice Address - State:NY
Practice Address - Zip Code:14534-9556
Practice Address - Country:US
Practice Address - Phone:585-329-9383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-23
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant