Provider Demographics
NPI:1356818900
Name:GATZKE, MACKENZI KAY (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MACKENZI
Middle Name:KAY
Last Name:GATZKE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:MACKENZI
Other - Middle Name:KAY
Other - Last Name:ROGERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:71 CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:DEADWOOD
Mailing Address - State:SD
Mailing Address - Zip Code:57732-1303
Mailing Address - Country:US
Mailing Address - Phone:605-717-6431
Mailing Address - Fax:605-717-8033
Practice Address - Street 1:71 CHARLES ST
Practice Address - Street 2:
Practice Address - City:DEADWOOD
Practice Address - State:SD
Practice Address - Zip Code:57732-1303
Practice Address - Country:US
Practice Address - Phone:605-717-6431
Practice Address - Fax:605-717-8033
Is Sole Proprietor?:No
Enumeration Date:2018-10-31
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1169363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD1169OtherSOUTH DAKOTA BOARD OF MEDICAL AND OSTEOPATHIC EXAMINERS