Provider Demographics
NPI:1376233353
Name:WEBSTER, MCKENZIE LEE (PA)
Entity Type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:LEE
Last Name:WEBSTER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 NEW BERN ST APT 339
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-4311
Mailing Address - Country:US
Mailing Address - Phone:704-604-5428
Mailing Address - Fax:
Practice Address - Street 1:3905 BROOKSIDE PKWY STE 300
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30022-4458
Practice Address - Country:US
Practice Address - Phone:770-442-1911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-11
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA12208363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty