Provider Demographics
NPI:1396391025
Name:RAUM, MCKENZIE BLAIR (PA-C)
Entity Type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:BLAIR
Last Name:RAUM
Suffix:
Gender:M
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 1:14995 SHADY GROVE RD STE 350
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-8726
Mailing Address - Country:US
Mailing Address - Phone:301-251-1433
Mailing Address - Fax:301-424-5266
Practice Address - Street 1:14995 SHADY GROVE RD STE 350
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-8726
Practice Address - Country:US
Practice Address - Phone:301-251-1433
Practice Address - Fax:301-424-5266
Is Sole Proprietor?:No
Enumeration Date:2019-08-19
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC07410363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant