Provider Demographics
NPI:1326008764
Name:MACKENZIE, JOHN R (CNP)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:MACKENZIE
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8387
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87198-8387
Mailing Address - Country:US
Mailing Address - Phone:505-269-6525
Mailing Address - Fax:505-792-5222
Practice Address - Street 1:502 ELM ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2512
Practice Address - Country:US
Practice Address - Phone:505-841-1000
Practice Address - Fax:505-843-2853
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR56021363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMPENDINGMedicare UPIN