Provider Demographics
NPI:1346707841
Name:ACCORSI, MACKENZIE JACQUELYN (PA-C)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:JACQUELYN
Last Name:ACCORSI
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 1:304 DETROIT ST
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46350-2497
Mailing Address - Country:US
Mailing Address - Phone:219-325-3770
Mailing Address - Fax:
Practice Address - Street 1:304 DETROIT ST
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-2497
Practice Address - Country:US
Practice Address - Phone:219-325-3770
Practice Address - Fax:219-325-8181
Is Sole Proprietor?:No
Enumeration Date:2019-02-21
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008969363A00000X
IN10002814A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant